g 


G.  W.  HARVEY.  M.  D. 

Physician  &  Surgeon, 

SALT  LAKE  CITY,  UTAH. 


O.  W.   HARVr 

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{JNEW 

pfj 


Eclectic  Medical  Practice ./ 


DESIGNED  FOR 


Students  and  Practitioners 

? 


H.  T. 


WEBSTER,  M.  D. 


Professor  of  the  Principles  and  Practice  of  Medicine  in  California  Medical  College ; 
Author  of  Dynamical  Therapeutics. 


VOLUME   I. 


Webster  Medical  Publishing  Co. 

1018  Washington  Street 

Oakland,  California 


— JJOO 


in? 


Copyright  1899 
BY  H.  T.  WEBSTER 


O.  W.   HARVEY,  M.  D. 

Physician &Sim 


PREFACE. 


THE  author  is  not  aware  that  an  urgent  demand  has  existed 
for  the  publication  of  this  book.  Indeed,  it  was  not  prepared  with 
the  impression  that  the  profession  was  in  urgent  need  of  it,  or 
that  it  would  prove  a  remarkable  innovation  in  the  medical  world. 
Medical  men  will  come  and  go  and  the  world  will  move  on,  after 
these  pages  have  passed  into  forge tfulness;  and  time  will  chroni- 
cle a  newer  practice — doubtless  a  better  one — when  the  years  have 
marked  the  inevitable  progress  of  events. 

The  students  of  the  California  Medical  College,  to  whom  the 
author  has  been  something  of  an  authority  on  practice  for  the  past 
sixteen  years,  have  frequently  importuned  him  to  publish  a  work 
which  would  embody  the  substance  of  his  lectures,  that  a  text- 
book for  ready  reference  might  be  had.  To  satisfy  this  demand 
the  present  volume  was  begun  several  year*  ago.  Other  duties, 
however,  have  delayed  the  work,  and  the  prospects  of  its  completion 
at  an  early  date  were  so  poor  that  at  the  request  of  several  mem- 
bers of  the  Class  of  '99  a  first  volume  has  been  published,  the 
second  to  follow  within  the  coming  two  years. 

Special  pains  have  been  taken  in  the  preparation  of  the  text  to 
dwell  on  the  description  of  disease,  that  there  may  be  no  need 
of  frequent  reference  to  allopathic  works  for  points  on  etiology, 
pathology,  symptoms,  diagnosis  and  prognosis.  At  the  same  time, 
it  has  been  the  author's  aim  to  render  the  book  as  complete  as  pos- 
sible on  that  which  has  been  the  peculiar  merit  of  Eclectic  works  on 
practice  in  the  past,  treatment. 

Attempt  has  been  made,  throughout  the  work,  to  give  every 
writer  from  whom  points  have  been  drawn  his  just  due,  especi- 
ally when  anything  appropriated  appeared  to  be  original  in  its 
conception.  As  appropriate  credit  has  thus  been  given,  it  would 


PREFACE. 

only  be  superfluous   to  reiterate   here   what  the   text   will  plaiuly 
show. 

Credence  has  been  given  the  teachings  of  bacteriology,  on  the 
ground  that  it  offers  the  only  reasonable  theory  for  the  spread 
of  infections  diseases  that  has  ever  yet  been  advanced.  Though 
there  are  those  who  scout  its  doctrines,  unfortunately  for  their 
skepticism  they  are  unable  to  offer  another  as  good  an  explanation 
of  the  spread  of  contagium.  Without  its  teachings  we  would  be  as 
gadly  at  sea  as  before.  Undoubtedly,  many  of  the  theories  of  bac- 
teriologists are  sound,  though  there  may  be  much  to  learn;  and 
there  may  be  some  things  taught  which  will  have  to  be  unlearned  at 
a  later  day.  Until  a  better  explanation  of  the  etiology  of  infectious 
diseases  has  been  offered,  however,  I  shall  follow  its  lead,  to  a  mod- 
erate extent,  at  least. 


G.  V7.   HARVEY.  M.  D. 

Physicians 


TABLE  OF  CONTENTS. 


SECTION  I. 
GENERAL  REMARKS  ON  FEVER  AND  INFLAMMATION. 

PAGE 

I.  Fever 1 

II.  Inflammation 17 

Hypertrophy 36 

Atrophy 37 

III.  Degenerations 41 

IAr.  Bacteriology 60 

SECTION  II. 
SPECIFIC  INFECTIOUS  DISEASES. 

I.  Typhoid  Fever 69 

II.  Typhus  Fever 90 

III.  Relapsing  Fever 97 

IV.  Cerebro-spinal  Fever 101 

V.  Small-pox , 108 

VI.  Vaccination 120 

VII.  Chicken-pox 123 

VIII.  Scarlet   Fever 128 

IX.  Measles 141 

X.  Rubella 150 

XI.  Mumps 153 

XII.  Whooping-cough 156 

XIII.  Epidemic  Influenza Itil 

XIV.  Dengue  Fever 165 

XV.  Diphtheria 167 

XVI.  Erysipelas 187 

XVII.  Septicaemia  and  Pyaemia 193 

XVIII.  Asiatic  Cholera 200 

XIX.  Yellow  Fever 208 

XX.  Malarial  Fever 216 

Intermittent  Fever --'2 

Remittent  Fever 22(> 

Pernicious  Malarial  Fever :M"> 

Typho-malarial  Fever -4:\ 

Chronic  Malarial  Fever ' 2.~>  1 

XXI.  Anthrax 258 

XXII.  Hydrophobia 260 

XXIII.  Tetanus... 


vi  CONTENTS. 

PAGE 

XXIV.  Acute  General  Tuberculosis 268 

X  X  V .  sy philis 273 

XXVI.  Leprosy 286 

XXVII.  Glanders 
XXVIII.  Airtinoraycosis 

XXIX.  Infectious  Diseases  of  Doubtful  Nature '2W 

Simple  Continued  Fever -'• : 

Weil's  Disease -'•'•"> 

Milk  Sickness '2\>~ 

Malta  Fever r "2w 

Miliary  Fever '2'.*> 

Mountain  Fever 300 

SECTION  III. 
CONSTITUTIONAL  DISEASES. 

I.  Rheumatism 301 

Acute  Articular  Rheumatism 303 

Subacute  Articular  Rheumatism 306 

Chronic  Articular  Rheumatism 307 

Muscular  Rheumatism 309 

II.  Pseudo-rheumatic  Affections 311 

Arthritis  Deformans 311 

Gonorrhopal  Rheumatism 315 

III.  Gout 316 

IV.  Lithaemia 323 

V.  Diabetes  Mellitus v ....  .".26 

VI.  Diabetes  Insipidus 331 

VII.  Rickets 333 

VIII.  Scurvy 338 

Infantile  Scurvy 341 

IX.  Purpura 342 

Purpura  Hemorrhagiru 343 

X.  Scrofula 344 

XI.  Haemophilia 346 

SECTION  IV. 
DISEASES  OF  THE  DIGESTIVE  ORGANS. 

I.  Diseases  of  the  Mouth 348 

Herpes  Lahialis 348 

Simple  Stomatitis 348 

Aphthous  Stomatitis 349 

Foetid  Stomatitis 350 

Mercurial  Stomatitis •'{."•] 

Eczema  of  the  Tongue '•'•'>- 

Parasitic  Stomatitis :>~>'2 

Gangrenous  Stomatitis 353 

Pyorrhoea  Alveolaris 354 

II.  Diseases  of  the  Salivary  Glands .  356 

Hyperseeretion  of  the  Salivary  Glands 356 

Arrest  of  the  Sah' vary  Secretion 357 

Inflammation  of  the  Sah' vary  Glands 358 

III.  Diseases  of  the  Pharynx 358 

Acute  Pharyngitis 358 


CONTENTS.  vii 

PAGE 

III.  Diseases  of  the  Pharynx,  Continued :{;> 

Phlegmonous  Pharyngitis 360 

Gangrenous   Pharyngitis , 360 

Chronic    Pharyngitis 362 

Ulceration  of  the  Pharynx 364 

Ludwig's  Angina 364 

IV.  Diseases  of   the  Tonsils 364 

Follicular  Tonsilitis 364 

Peritonsillar  Abscess 366 

Chronic   Tonsillitis 368 

V.  Diseases  of  the  (Esophagus 371 

(Esophagitis 371 

Obstruction  of  the  (Esophagus 373 

Functional  Disease  of  the  (Esophagus 374 

VI.  Diseases  of  the  Stomach 376 

Acute  Gastritis 376 

Phlegmonous  Gastritis 378 

Parasitic  Gastritis 379 

Chronic  Gastritis 379 

Dilatation  of  the  Stomach 390 

Peptic  Ulcer 392 

Cancer  of  the  Stomach 398 

Non-malignant  Tumors  of  the  Stomach 403 

Haematemesis 404 

Functional  Gastric  Dyspepsia 406 

Hypersecretion  and  Hyperacidity 408 

Gastralgia 409 

Peristaltic  Unrest 411 

Rumination 411 

VII.  Diseases  of  the  Intestines 411 

Morning  Diarrhoea 411 

Acute  Intestinal  Catarrh 412 

Chronic  Intestinal  Catarrh 415 

Phlegmonous  Enteritis 418 

Pseudo-membranous  Enteritis 418 

Mucous  Colitis 419 

Ulcerative  Enteritis 420 

Dysentery 4l!f> 

Cholera  Morbus 431 

Cancer  of  the  Intestine 433 

Intestinal  Obstruction 437 

Intestinal  Hemorrhage 441 

Typhlitis 443 

Appendicitis 444 

Proctitis 449 

Periproctitis 450 

Hemorrhoids 451 

Amyloid  Degeneration  of  the  Bowels 455 

Diarrhoea 456 

Constipation 458 

Intestinal  Colic 461 

Estival  Infantile  Enteritis 464 

VIII.  Diseases  of  the  Mesentery 470 

Miscellaneous  Affections 470 

IX.  Diseases  of  the  Liver 471 

Jaundice .' 471 

Infantile  Jaundice. . .  474 


CONTENTS. 

PAGE 

IX.  Diseases  of  the  Liver,  Continued 471 

Malignant  Jaundice 476 

Abnormalities  of  the  Hepatic  Circulation 478 

Interstitial  Hepatitis 480 

Abscess  of  the  Liver 486 

New  Growths  in  the  Liver 490 

Fatty  Liven. 493 

Amyloid  Liver 495 

Tuberculosis  of  the  Liver 496 

X.  Diseases  of  the  Bile  Passages 497 

Catarrhal  Inflammation  of  the  Biliary  Passages 497 

Gall-stones 498 

XI.  Diseases  of  the  Pancreas 508 

Hemorrhage 503 

Acute  Pancreatitis 504 

Chronic  Pancreatitis 505 

Fatty  and  Waxy  Degeneration 506 

Cancer  of  the  Pancreas 507 

Calculi  and  Cysts 507 

XII.  Diseases  of  the  Peritonaeum 508 

Acute  General  Peritonitis 508 

Peritonitis  in  Infants •"•  1  - 

Localized   Peritonitis 512 

Chronic  Peritonitis 513 

New  Growths  in  the  Peritonaeum 515 

Ascites . .  . .  516 


NEW   ECLECTIC   MEDICAL  PRACTICE. 

VOLUME     I. 


SEGTIOI2   I, 

GENEEAL  EEMAEKS  ON  FEVEE  AND  INFLAMMATION. 


I.  FEVERS. 

Synonyms. — Febris;  Pjr;  Pyretus;  Pyrexia. 

Definition, — A  pathological  condition  characterized  by  eleva- 
tion of  temperature,  acceleration  of  pulse,  disturbance  of  circulation, 
arrest  of  secretion  and  excretion  to  a  certain  extent,  disturbance  of 
innervation,  and  loss  of  flesh. 

General  Classification, — Fevers  have  been  divided  into  two 
general  classes.  In  one  the  exciting  cause  is  a  zymosis,  which  pro- 
vokes a  primary  constitutional  disturbance  (idiopathic),  while  in  the 
other  class  the  febrile  action  is  secondary  to  a  localized  inflamma- 
tion. But  modern  writers  have  discarded  this  classification,  it  being 
apparent  from  comparatively  recent  discoveries  in  bacteriology  that 
the  difference  in  many  cases  is  more  apparent  than  real.  The  mod- 
ern classification  would  be  into  Infectious  Fevers  and  Non-infectious 
Fevers,  both  classes  including  certain  forms  of  idiopathic  and  symp- 
tomatic fever  of  the  old  classification.  In  the  present  work  no 
attempt  at  strict  classification  will  be  made,  as  the  subject  is  yet  in 
an  unsettled  state,  and  infectious  fevers  will  therefore  be  classed 
with  acute  infectious  diseases. 

The  Detection  of  Fever, — The  diagnostic  symptom  of  fever 
is  an  elevation  of  the  temperature  of  the  body  above  the  normal 
range  (98. 5C  F.,  approximately).  All  other  indications  of  fever,  such 
as  acceleration  of  pulse,  disturbance  of  circulation,  arrest  of  secretion 
and  excretion  to  a  certain  extent,  etc.,  may  be  present,  and  yet 


2  INTRODUCTION. 

without  a  disturbance  of  the  temperature  there  will  be  no  fever. 
However,  in  exceptional  cases  at  particular  periods  it  may  be 
below  instead  of  above  the  normal  rate.  The  temperature-changes 
are  detected  by  the  use  of  the  clinical  thermometer. 

Thermometry. — The  ordinary  thermometer  consists  of  a  glass 
tube  marked  with  the  degrees,  and  terminating  at  the  lower  extrem- 
ity in  a  bulb  which  contains  the  bulk  of  the  mercury,  a  portion  of 
this  rising  into  the  tube  and  being  further  raised  as  warmth  is 
applied  to  the  bulb.  A  detached  portion  of  mercury  ( the  register ) 
is  separated  from  the  main  column  and  remains  stationary  after 


CLINICAL  THERMOMETER.    (  O.  L,  J.) 

cooling,  marking  the  highest  point  reached  during  each  trial.  This 
should  be  shaken  down  below  95°  each  time  before  using  the  instru- 
ment. Before  and  after  using,  the  thermometer  should  be  sterilized, 
especially  in  case  of  infectious  diseases.  In  testing  the  tempera- 
ture the  bulb  may  be  placed  in  the  mouth,  axilla,  or  rectum,  as  may 
be  most  convenient  or  seem  most  appropriate.  In  females  the  vagina 
may  be  resorted  to  instead.  In  order  to  insure  full  expansion  of 
the  mercury  the  bulb  should  remain  in  position  for  fully  five  min- 
utes, care  being  taken  to  exclude  the  air  by  closing  the  lips  when 
the  bulb  is  under  the  tongue,  or  holding  the  arm  snugly  to  the  side 
when  it  is  in  the  axilla.  Delirious  and  comatose  patients  cannot 
be  relied  upon  to  retain  the  bulb  in  the  mouth,  and  the  axilla  should 
then  be  resorted  to.  Packs  or  other  dressings  about  the  chest  may 
then  render  it  preferable  to  introduce  the  instrument  into  the  rec- 
tum. Where  the  thermometer  is  a  bugaboo  to  timorous  children 
the  rectum  should  be  chosen.  The  temperature  of  the  rectum  is 
about  one  degree  higher  than  that  of  the  axilla. 

Stages  of  Fever. — It  has  been  a  time-honored  custom  to  name 
the  three  stages  of  fever  the  "cold,"the  "hot,"  and  the  "sweating"  stage, 
respectively.  These  names  have  been  abandoned  by  modern  author^. 
however,  as  the  sensation  of  chilliness  is  not  always  noticeable 
during  the  first  stage,  and  the  thermometer  may  demonstrate  a 
marked  rise  of  temperature  even  while  the  subject  is  experiencing 
the  chilliness.  Better  terms,  then,  are:  (1)  the  stage  of  invasion ;  (2) 
stage  of  acine,  fastigium,  or  stadium;  and  (3)  stage  of  defervescence, 
or  decline.  The  stage  of  invasion  in  malarial  fevers  and  others 
occurring  in  markedly  malarious  regions  is  usually  signalized  by 
a  marked  chill,  or  rigor.  Outside  of  such  influence,  the  chilly  stage 


FEVER.  3 

of  typhoid  fever,  scarlatina,  measles,  etc.,  may  or  may  not  be  notice- 
able. During  the  stage  of  invasion  the  temperature  is  rising.  Dur- 
ing the  stage  of  acme,  fastigium,  or  stadium,  it  inclines  to  touch, 
repeatedly,  the  highest  point;  and  during  the  stage  of  defervescence 
or  decline,  it  is  falling,  either  rapidly  or  by  gradations,  toward  the 
normal  point. 

Termination  of  Fever. — Fever  may  terminate  (1)  by  crisis, 
and  (2)  by  lysis.  Crisis  is  characterized  by  rapid  and  permanent 
decline  of  temperature;  a  decline  of  four  or  five  degrees  occurring  in 
twenty-four  hours,  with  sudden  establishment  of  all  the  secretions 
and  excretions,  with  disappearance  of  nervous  symptoms  and  other 
discomfort.  Lysis  is  attended  by  a  gradual  fall  of  temperature  or 
by  remitting  gradations,  the  morbid  symptoms  subsiding  gradually, 
the  stage  occupying  several  days  or  a  week. 

Febrile  Remissions. — Prior  to  the  general  use  of  the  fever- 
thermometer  among  physicians  fevers  were  divided  into  two  gen- 
eral classes,  a  division  which  the  thermometer  has  shown  to  be 
faulty.  The  malarial  fevers  were  classed  as  periodic;  and  enteric, 
typhus  fever,  and  the  exanthemata,  were  classed  as  continued.  But 
the  thermometer  demonstrates  that  all  fevers  manifest  a  diurnal 
variation  of  temperature,  the  minimum  being  reached  about  6  A.  l£., 
and  the  maximum  about  6  p.  M.  Therefore,  no  fever  is  continued,  in 
the  sense  suggested.  However,  certain  forms  are  so  nearly  continu- 
ous in  the  maximum  range  that  they  are  classed  as  Continued  Fevers, 
though  the  arrangement  is  different  from  the  old  one.  Typhus  fever, 
scarlatiua,  and  sometimes  typhoid,  in  which  the  variation  between 
the  maximum  and  minimum  temperature  is  only  1°  to  1.5°,  may  be 
included  in  this  division.  In  another  division  there  are  marked 
diurnal  remissions,  but  the  minimum  never  reaches  the  normal  point 
during  the  fastigium,  and  only  at  or  near  the  end  of  the  decline. 
These  are  properly  Remittent  Fevers.  Examples  of  this  type  are 
typhoid  (usually),  malarial  remittent,  and  hectic.  In  still  another 
class  the  temperature  falls  to  normal  or  below  that  point,  during  the 
diurnal  decline.  Such  are  classed  as  Intermittent  Fevers.  The  prin- 
cipal intermittent  fevers  are  malarial  intermittent,  relapsing,  hectic 
(occasionally,  though  usually  remittent),  and  Charcot's  intermittent 
(gall-stone  fever).  It  will  be  observed  that  this  classification  can- 
not be  very  permanent,  as  severe  cases  of  typhoid  may  hardly  show 
diurnal  variation  of  temperature  at  all,  while  mild  cases,  or  those 
complicated  with  malaria,  usually  manifest  marked  remissions  and 
exacerbations. 

Causes  of  Fever. — The  presence  of  microorganisms  or  their 
alkaloids  (toxines)  in  the  blood;  local  inflammations  acting  as 


4  INTRODUCTION. 

exciting  causes;  the  products  of  fatty  metabolism;  and  paralysis  of 
the  heat  center. 

Parasitic  Origin  of  Fevers. — The  past  few  years  have  thrown 
much  new  light  upon  the  origin  of  infectious  fevers.  The  micro- 
scope has  opened  a  naw  era  in  the  etiological  phase  of  these  dis- 
eases, and  rendered  obsolete  doctrines  respecting  causation  formerly 
promulgated.  It  is  not  impossible  that  changes  may  yet  occur  in 
views  which  are  now  almost  universally  accepted,  but  it  hardly 
seems  that  so  many  observers  can  be  mistakan  as  to  the  identity  of 
the  germs  which  are  believed  to  be  the  exciting  factors  in  several  of 
the  different  forms  of  this  class  of  diseases.  If  it  be  granted  that 
the  new  doctrine  is  established  in  a  single  instance  it  cannot  be 
doubted  that  all  diseases  of  the  same  class — contagious  and  infec- 
tious fevers — will  finally  be  traced  to  similar  causes,  and  their  spe- 
cific germs  pointed  out  and  described. 

It  is  pretty  certain  that  infectious  fevers  depend  for  their  origin 
and  spread  upon  the  propagation  and  transmission  of  specific  micro- 
Organisms  which  are  conveyed  from  sick  to  well,  either  directly  or 
through  fomites  -which  serve  to  preserve  and  convey  them,  each  dis- 
ease depending  upon  its  own  particular  germ,  and  never  originating 
spontaneously.  Some  microorganisms  have  special  indigenous 
habitats  where  they  exist  perpetually,  to  be  widely  disseminated 
under  favoring  influences,  afterward  dying  out,  except  in  their  favor- 
ite haunts.  Such  is  the  character  of  cholera,  which  is  indigenous  to 
East  India;  yellow  fever,  indigenous  to  the  Antilles;  and  typhus 
fever,  indigenous  to  Northern  Europe.  Others,  when  they  invade 
new  territory,  remain  there  permanently,  on  account  of  the  power 
of  the  germs  to  resist  external  influences,  hibernating  at  times  and 
possibly  gaining  strength  from  filth  and  putrefaction.  Examples  of 
such  are  diphtheria  and  typhoid  fever. 

Infection,  then,  may  be  said  to  be  the  development,  within  the 
blood,  from  a  transmitted  germ  or  microorganism,  of  a  colony  of  the 
same  species,  the  excretions  and  secretions  of  which  give  rise  to 
poisonous  ptomaines  (toxines),  resulting  in  general  sepsis  of  the 
fluids  of  the  body,  and  consequent  destructive  action  upon  the  blood 
and  tissues.  All  organisms,  during  their  activity,  produce  more  or 
less  waste  or  excrementitious  material,  which,  in  the  case  of  the 
infectious  microbe,  constitutes  the  poisonous  element.  The  virulence 
of  the  poison  depends  upon  the  individuality  of  the  microorganism, 
and  this  accounts  for  the  comparative  severity  of  some  infectious 
diseases  and  the  mildness  of  others ;  while  the  condition  of  the  sys- 
tem in  different  individuals,  or  their  power  of  resistance  to  disease, 
may  account  for  mild  and  severe  cases  in  the  same  home  at  the 


FEVER.  6 

same  time.  A  comparative  severity  and  mildness  of  different  epi- 
demics is  also  observable,  depending  largely  probably  upon  hygienic 
surroundings  and  atmospheric  influences. 

The  human  system  may  be  infected  with  either  vegetable  para- 
sites or  microorganisms  (bacteria),  or  minute  animal  organisms 
(hsematozoa).  Many  of  the  bacteria  are  self-limiting  in  the  human 
system,  perishing  either  from  lack  of  nourishing  pabulum,  from  poi- 
soning by  their  own  toxines,  by  phagocytosis,  or  in  some  way  not 
yet  suggested,  thus  leaving  the  individual  completely  or  partially 
protected  from  subsequent  attacks.  The  hsematozoa  of  Laveran, 
which  are  supposed  to  be  the  microorganisms  of  malaria,  do  not 
produce  the  severe  septic  effects  caused  by  some  of  the  bacteria, 
are  not  self-limiting,  and  if  the  disease  they  cause  be  arrested  there 
is  left  a  predisposition  to  a  return  of  the  malarial  manifestation. 
It  is  possible  that  when  the  blood  is  once  infected  with  malaria  the 
principle  may  remain,  in  a  more  or  less  active  state,  perpetually. 

The  study  of  the  microorganisms  of  disease  belongs  to  bacteriol- 
ogy, and  no  more  reference  will  be  made  to  it  in  these  pages  than  is 
necessary  to  discuss  the  practice  of  medicine  intelligently.  Really, 
Eclectics  realized  the  importance  of  correcting  septic  processes,  and 
had  adapted  specific  agents  to  their  correction,  long  before  they 
were  known  to  be  caused  by  microorganisms ;  and  we  can  do  but  lit- 
tle better,  if  any,  in  treatment  now.  But  we  have  gained  an  impor- 
tant advantage  in  preventive  medicine,  and  can  now  treat  the  subject 
with  an  intelligence  and  positiveness  not  possible  with  previous  lack 
of  information. 

Symptoms  of  Fever. — Elevation  of  temperature,  arrest  of 
secretion  and  excretion,  acceleration  of  the  pulse  and  respiration, 
disturbance  of  the  nervous  system,  coated  tongue,  traces  of  albu- 
men in  the  urine,  deposit  of  urates,  loss  of  flesh  and  strength. 

The  temperature  varies  much  in  its  maximum  height  in  different 
cases,  and  in  its  average  maximum  height  in  different  forms.  Some 
fevers  are  characterized  by  an  unusally  high  maximum  temperature, 
and  the  moderate  rate  is  the  exception.  Such  are  typhoid  fever, 
scarlatina,  typhus  and  relapsing  fevers.  Others  are  fevers  of  low 
maximum  temperature,  as  a  rule,  such  as  rubella,  cerebro-spinal 
fever,  and  measles.  Some  protracted  fevers  which  terminate  by 
slow  lysis  are  marked  near  the  close  by  subnormal  temperature,  the 
thermometer  registering  below  97.5°  F.  during  the  morning  remis- 
sions. The  subnormal  temperature  is  rather  common  to  the  conva- 
lescent period  of  typhoid  fever  and  pneumonia ;  also  in  collapse  from 
shock,  hemorrhage,  heart  failure;  or  perforation  of  visceral  walls, 
as  of  the  bowel  in  typhoid  fever,  the  lung  in  phthisis,  or  the  stomach 


6  INTRODUCTION. 

in  round  ulcer.  The  temperature  may  be  subnormal  in  certain  chronic 
diseases,  such  as  diabetes,  cancer,  and  chronic  cardiac,  cerebral, 
and  spinal  affections.  The  temperature  of  cholera  is  remarkably  sub- 
normal, it  frequently  remaining  at  90° — 85°  for  several  days. 

The  temperature  of  some  fevers  follows  a  pretty  constant  course, 
in  the  majority  of  cases;  thus,  the  temperature  of  typhoid  fever 
runs  a  typical  course  usually,  and  so  does  that  of  typhus,  relapsing, 
malarial,  and  other  fevers.  Others  are  notoriously  irregular  in  this 
respect — cerebro-spinal  fever  and  diphtheria,  for  example.  Complica- 
tions are  marked  by  sudden  changes  of  temperature,  thus:  The  ad- 
vent of  nephritis  or  inflammation  of  other  important  organ  in  scar- 
latina, diphtheria,  etc.,  is  announced  by  a  rapid  rise  of  temperature; 
intestinal  hemorrhage  in  typhoid  fever  is  characterized  by  abrupt 
decline  of  temperature;  etc.  In  all  severe  cases  of  protracted  fever, 
frequent  use  of  the  thermometer  will  enable  the  practitioner  to 
detect  complications  much  earlier  than  he  otherwise  would,  and 
will  prepare  him  for  proper  therapeutic  adaptation  at  an  early  stage, 
when  his  change  of  treatment  may  be  of  benefit. 

Wunderlich  has  made  the  following  classification  of  the  tempera- 
ture of  fever,  which  is  worthy  of  record : 

1.  Subfebrile ;  temperature  99.5°— 100.4°. 

2.  Slightly  febrile;  temperature  100.4°— 101.3°. 

3.  Moderately  febrile;  temperature  101.3°— 103.1°. 

4.  Decidedly  febrile ;  temperature  103.1°— 104°. 

5.  Highly  febrile;  temperature  103.1°  in  the  morning  and  above 
104.9°  in  the  evening. 

6.  Hyperpyretic ;  above  106°. 

A  moderately  elevated  temperature  without  remission  is  more  to 
be  feared  than  one  that  is  much  higher  in  its  maximum  but  which 
declines  markedly  each  twenty-four  hours. 

The  pulse  is  increased  in  frequency  in  most  fevers,  though  dur- 
ing the  stage  of  calm  in  yellow  fever  it  becomes  remarkably  slow, 
being  reduced  to  forty  or  fifty  per  minute;  and  in  malignant  forms 
of  malarial  fever  it  may  be  abnormally  slow.  The  pulse  is  easily 
disturbed  by  slight  causes  in  early  childhood,  and  is  then  not  of  much 
importance  as  a  symptom,  either  in  diagnosis  or  prognosis.  The 
quality  of  the  pulse  is  as  important  as  its  frequency ;  the  small 
pulse  of  debility,  the  strong  pulse  of  sthenia,  the  full,  hard  pulse 
of  obstruction,  the  full,  bounding  pulse  of  sthenia  with  arterial  relax- 
ation, the  oppressed  pulse  of  capillary  congestion,  the  sharp,  wiry 
pulse  of  nervous  irritation,  the  feeble,  fluttering  pulse  of  impending 
dissolution  or  cardiac  debility,  each  carries  its  suggestion  to  the 
observant  practitioner. 


FEVER.  7 

Disturbance  of  the  nervous  system  may  vary  from  slight  restless- 
ness to  extremely  violent  delirium,  in  which  it  may  be  necessary  to 
employ  force  to  prevent  the  patient  from  getting  out  of  bed.  Two 
kinds  or  qualities  of  nervous  disturbance  are  observable  in  different 
cases ;  viz.,  that  of  active  irritability,  and  that  of  oppression  or  drows- 
iness. In  one  there  is  irritation,  and  in  the  other  there  is  intoxica- 
tion, from  the  disturbing  toxine.  The  active  symptoms  are  most 
liable  to  appear  early  in  the  course  of  a  fever,  and  the  second  later  on, 
though  either  may  be  marked  from  the  beginning,  while  in  other 
cases  the  nervous  symptoms  may  not  be  at  all  prominent  at  any  time. 

The  tongue  furnishes  important  symptoms  in  many  cases  of  fever 
regarding  diagnosis,  prognosis,  and  treatment.  The  tongue  of  scarla- 
tina is  peculiar  and  almost  diagnostic,  that  of  gastric  irritation  un- 
mistakable, and  other  morbid  conditions  are  just  as  certainly  shown 
by  the  tongue.  We  are  enabled  to  select  many  remedies  with  tolera- 
ble certainty,  and  thus  meet  varying  conditions  of  disease  with  a  read- 
iness not  otherwise  possible.  Special  notice  will  be  given  this  sub- 
ject under  the  head  of  treatment 

Tissue  Changes  Resulting  from  Fever. — High  and  long- 
continued  fever  results  in  considerable  change  in  the  quality  of  the 
tissues,  the  amount  of  fever  bearing  an  important  relation  to  the  ex- 
tent of  morbid  change.  After  high  and  prolonged  fever  the  different 
organs  are  more  or  less  swollen,  opaque,  and  friable.  Evidence  of 
recent  circulatory  disturbance  is  furnished  by  the  injected  vessels 
and  general  oedema.  Microscopic  appearances  indicate  marked 
alteration  of  histological  elements;  the  cellular  elements  are  increased 
in  size  and  their  protoplasm  has  become  granular,  obscuring  the 
nucleus.  The  granular  condition  is  due  to  the  presence  of  albumen 
and  fatty  particles.  The  tissue-changes  occur  most  markedly  in 
pyaemia,  erysipelas,  typhus,  typhoid,  and  other  infectious  fevers,  and 
in  acute  rheumatism.  Alterations  may  be  so  extreme  as  to  amount 
to  necrotic  changes,  such  as  those  in  the  tissues  of  the  liver  in  yel- 
low fever,  though  this  is  probably  due  largely  to  the  specific  char- 
acter of  the  disease.  The  organs  in  which  pyrexial  changes  are 
most  observable  are  the  liver,  the  heart,  the  kidneys,  the  muscles, 
and  the  lungs. 

General  Treatment  of  Fever. — Rest  in  bed  is  the  first 
essential,  and  the  earlier  the  patient  gives  up  exertion  and  affords 
every  assistance  possible  in  this  way  the  better  are  his  chances  of 
an  early  recovery.  In  many  cases  the  early  symptoms  are  so  urgent 
that  the  patient  succumbs  at  once  and  goes  to  bed;  but  in  other 
cases,  such  as  typhoid  fever  for  example,  the  onset  may  be  so  insid- 
ious that  he  may  remain  about  and  on  his  feet  until  his  recuperative 


8  INTRODUCTION. 

energies  are  too  nearly  exhausted  to  assist  him  through  the  trying 
ordeal  which  follows.  But  physical  rest  is  not  the  only  essential 
here.  Where  there  is  the  least  tendency  to  nervous  irritability,  the 
room  should  be  darkened  and  all  noise  strictly  prohibited.  Talking 
must  not  be  allowed  in  the  sick  room ;  even  whispering  must  be  pro- 
hibited. 

Ventilation  is  also  highly  important  in  the  treatment  of  fevers, 
especially  those  of  an  infectious  character.  The  emanations  from  sub- 
jects affected  with  diphtheria,  typhoid,  typhus,  or  yellow  fever,  in  an 
unveutilated  room,  are  always  additional  elements  of  danger.  It 
has  been  observed  in  epidemics  of  both  typhus  and  yellow  fever 
that  patients  who  have  been  carried  out  of  hospital  wards  in  an 
apparently  hopeless  condition  into  the  open  air  have  revived,  and 
in  some  cases  gone  on  to  complete  recovery;  and  it  is  a  favorite  prac- 
tice with  those  of  extensive  experience  with  these  diseases  to  treat 
them  in  tents  or  open  barracks.  But  neglect  of  ventilation  must  not 
be  permitted  in  any  infectious  disease,  though  in  such  an  instance  as 
measles  cold  air  is  not  allowable,  on  account  of  its  irritating  influ- 
ence upon  the  sensitive  respiratory  membrane.  The  temperature 
of  a  fever  apartment  should  ordinarily  be  about  60°  F.,  though  no 
rule  can  be  laid  down  to  supplant  the  discretion  of  the  physician  in 
individual  cases.  In  each  case  the  temperature  should  be  maintained 
at  about  the  same  degree  of  warmth  throughout  the  disease. 

The  diet  in  fevers  should,  as  a  rule,  be  liquid  or  semi- solid.  In 
most  fevers  morbid  changes  occur  in  the  mucosa  of  the  alimentary 
canal  which  incapacitate  this  tract  for  the  performance  of  its  usual 
functions.  As  a  liquid  diet  is  more  easily  digested  and  assimilated, 
it  must  consequently  be  the  appropriate  form  for  use.  In  case 
of  typhoid  fever  the  use  of  solid  food  is  absolutely  dangerous,  haz- 
arding perforation  of  the  weakened  intestinal  wall;  while  in  diphthe- 
ria and  scarlatina  a  liquid  diet  is  more  readily  swallowed.  Doubt- 
less, the  natural  efforts  required  for  the  digestion  of  solid  food  dis- 
turb the  heat  center  indirectly,  and  so  occasion  more  or  less  rise  in 
temperature.  Therefore,  in  all  protracted  fevers  especially,  a  liquid 
diet  is  the  only  admissible  form  of  food  for  use.  But  it  is  riot  aloue 
requisite  that  the  diet  shall  be  liquid.  Quality  must  be  considered. 
It  was  once  believed  that  beef  tea  was  all  the  food  necessary  for  a 
fever  patient,  but  it  is  now  generally  conceded  that  one  would  starve 
in  time  if  fed  upon  nothing  but  this  article.  It  has  been  asserted, 
with  good  reason,  that  it  contains  no  more  nourishment  than  urine. 
Kepresenting,  as  it  does,  the  products  of  a  destructive  metabolism, 
it  hardly  seezns  capable  of  even  exerting  the  stimulant  influence 
attributed  to  it  Nourishment  is  an  important  qualification  of  liquid 


FEVER.  9 

foods,  and  we  find  this  varying  in  amount  in  different  kinds.  Milk 
is  a  leading  article  in  this  line,  bub  its  use  is  attended  by  the  objec- 
tion that  the  curd  which  forms  after  it  becomes  acidulated  in  the 
stomach  may  become  a  firm  and  resisting  mass,  difficult  to  dispose 
of.  This  objection,  however,  may  be  obviated  by  adding  from  one 
to  two  ounces  of  lime-water  to  each  pint  of  milk  before  using.  In 
these  days  prepared  foods  have  done  away  with  many  of  the  problems 
of  old  in  the  feeding  of  fevers.  Among  those  to  be  especially  com- 
mended are  malted  milk,  lactated  food,  and  Mellin's  food.  I  have 
fed  many  cases  of  typhoid  fever  on  Mellin's  food  throughout,  with 
most  excellent  satisfaction.  Vegetable  broths,  soups,  and  gruels  are 
excellent  alternates  when  the  animal  foods  become  objectionable; 
and  some  of  them  are  very  nourishing,  such  for  instance  as  rice 
water,  bean  soup,  and  oat  and  cornmeal  gruels,  though  these  should 
be  carefully  strained  when  used  in  enteric  fever.  Food  should  be 
given  often  and  in  small  quantities  during  the  active  stages  of  pro- 
tracted fevers,  the  same  regularity  and  promptitude  being  observed 
as  in  the  administration  of  medicine. 

In  most  cases  of  fever  the  fauces  are  dry  and  thirst  is  an  urgent 
symptom.  There  is  no  objection  to  the  free  use  of  water  in  such 
cases,  unless  there  be  gastric  irritability  with  rejection  of  fluids  as 
soon  as  swallowed;  in  which  case  the  stomach  must  be  given  complete 
rest  and  proper  medication  for  a  time,  while  the  thirst  is  palliated 
by  packing  the  epigastric  region  with  a  folded  towel  which  has  been 
wrung  out  of  cold  water,  or  by  using  a  rectal  injection  of  cold  water,  to 
be  retained.  Liquid  diet  answers  well  here,  sustaining  as  well  as 
relieving  thirst,  and  whey,  barley-water,  toast-water,  koumiss,  lem- 
onade sweetened  with  maltine  or  grape-sugar,  tamarind-water,  and 
many  other  articles  may  be  selected  to  satisfy  the  taste,  or  to 
conform  to  other  requirements.  Bits  of  ice  may  be  held  in  the  mouth 
and  allowed  to  dissolve,  but  this  must  not  be  carried  too  far,  for 
fear  of  embarrassing  recuperative  processes  by  chilling  the  stomach. 

In  all  protracted  fevers  the  danger  of  permitting  the  patient  to 
remain  continually  in  one  position  should  not  be  overlooked. 
Hypostatic  congestion  of  the  lungs  is  almost  certain  to  follow  where 
a  person  is  allowed  to  lie  upon  the  back  or  in  any  other  fixed  position 
for  a  long  time,  and  fatal  sequelae  are  very  liable  to  follow  getting 
up,  from  the  pulmonary  complication.  Bed  sores  are  always  a  men- 
ace, and  liability  to  them  is  much  increased  when  pressure  is  made 
constantly  upon  one  part  for  protracted  periods.  It  is  the  duty  of 
the  physician  to  know  these  facts,  and  to  instruct  attendants  to  turn 
the  patient  every  three  or  four  hours,  so  that  he  may  lie  a  portion  of 
the  time  on  each  side  and  a  portion  of  the  time  on  the  back. 


10  INTRODUCTION. 

The  medicinal  treatment  of  fevers  will  vary  considerably  in  differ- 
ent varieties,  and  also  in  different  cases  of  the  same  character.  In 
brief,  there  can  be  no  fixed  course  to  pursue,  but  each  case  must  be 
individualized,  and  treated  as  a  separate  proposition.  It  may 
seem  from  this  statement  that  the  subject  must  be  a  very  com- 
plicated one,  then,  but  this  is  not  so,  for  a  proper  understand- 
ing of  the  principles  involved  reduces  the  problem  to  a  few  simple 
propositions. 

While  remote  causes  of  fever  have  been  noticed,  it  is  to  be  remem- 
bered that  toxines  generated  by  the  presence  of  parasites  or  other 
impurities  are  the  immediate  elements  to  be  considered.  Though 
the  foreign  element  may  have  been  provocative  of  the  condition, 
nature  has  apparently  provided  the  means  for  its  final  elimination, 
if,  in  the  meantime,  the  zymotic  action  has  not  been  so  extensive 
as  to  destroy  the  life  of  the  patient.  It  appears  to  many  that 
efforts  of  therapeutists  toward  the  destruction  of  disease-producing 
germs  after  they  have  entered  the  circulation  will  always  prove 
futile,  as  many  germs  are  capable  of  resisting  the  action  of  drugs 
powerful  enough  to  destroy  human  life  when  swallowed.  In  the 
rational  treatment  of  fevers,  then,  we  will  limit  ourselves  to  the  man- 
agement of  the  poisonous  ptomaines  generated,  and  their  effects. 

One  of  the  great  dangers  in  fever  lies  in  the  high  temperature 
which  attends  many  cases.  This  interferes  with  secretion  and  excre- 
tion, and  encourages  degeneration  of  tissue,  wasting,  and  loss  of 
strength,  as  well  as  favoring  fatal  changes  in  such  delicate  and  sen- 
sitive organs  as  the  brain,  lungs,  and  other  vital  parts.  We  will 
strive,  then,  from  the  commencement  of  treatment  to  lower  the  maxi- 
mum temperature  toward  the  normal  point  by  every  safe  and  rational 
means.  The  popular  plan  for  the  accomplishment  of  this  purpose 
among  the  most  successful  class  of  practitioners  is  the  use  of  the 
special  sedatives,  in  minute  and  frequently  repeated  doses. 
The  recognised  special  sedatives  are:  aconite,  belladonna,  gelsemium, 
jaborandi,  veratrum,  and  rims  tox.  Though  powerful  depressants  in 
large  doses,  these  remedies  exert  a  remarkably  calmative  effect  upon 
the  circulation  in  many  cases  of  fever,  without  depressing,  when 
administered  in  minute  doses,  and  repeated  as  often  as  every  hour, 
day  after  day.  Not  only  are  the  force  and  rapidity  of  the  circulation 
and  frequency  of  the  heart's  action  diminished,  but  nervous  ere- 
thism is  calmed,  and  secretion  promoted.  Each  one  manifests 
decided  peculiarities  which  adapt  it  to  special  cases  or  conditions. 
These  conditions  are  suggested  by  the  character  of  the  pulse  usu- 
ally, though  other  symptoms  may  assist  in  the  selection  of  the  cor- 
rect agent.  The  following  hints  are  submitted: 


FEVER.  11 

Aconite  is  the  remedy  for  the  ordinary  fever  of  debility  in  mid- 
dle life,  in  children^  and  elderly  adults.  The  characteristic  pulse  is 
small  and  rapid,  but  distinct  and  regular  (not  wiry).  It  is  applica- 
ble to  infectious  as  well  as  non-infectious  fevers,  while  it  assists  in 
controlling  local  inflammation,  especially  that  of  mucous  mem- 
branes. It  is  calming  to  conditions  of  nervous  excitability,  though 
not  as  useful  as  rhus  tox.  where  this  symptom  is  marked.  It  pro- 
motes normal  secretion,  especially  from  the  skin  and  mucous  mem- 
branes; and  though  it  quiets  excitement  of  the  circulatory  organs,  it 
doubtless  improves  their  normal  energy  at  the  same  time.  In  using, 
for  an  adult,  add  five  or  eight  drops  of  Lloyd's  or  Worden's  aco- 
nite to  four  ounces  of  water,  and  administer  a  teaspoonful  every 
hour. 

Belladonna  furnishes  us  with  two  peculiarities  of  action,  depend- 
ing upon  the  method  of  administration.  When  half  a  drachm  or  a 
drachm  of  the  third  decimal  dilution  is  added  to  four  ounces  of  water, 
and  a  teaspoonful  given  every  hour,  it  is  applicable  to  debilitated 
conditions  marked  by  furious  delirium.  In  this  case  the  eyes  are 
wild,  the  face  is  flushed  bright  red,  the  mind  abnormally  active  and 
aggressive,  while  the  pulse  is  small,  feeble,  and  oppressed,  and  the 
patient  markedly  prostrated.  In  the  other  case  we  obtain  its  effects 
from  more  material  doses.  Adding  five  or  ten  drops  of  the  specific 
medicine  or  a  green  plant  tincture  to  four  ounces  of  water  we  have 
a  remedy  for  febrile  conditions  attended  by  feeble  capillary  circula- 
tion, suggested  by  coldness  of  the  extremities,  feeble,  oppressed 
pulse,  inelastic  tissues,  dullness  or  drowsiness,  sensation  of  swim- 
ming in  the  head,  dilatation  of  the  pupil,  muttering  delirium,  etc. 

Gelsemium  is  the  remedy  for  febrile  conditions  in  sthenic  sub- 
jects, at  least  those  in  which  prostration  is  not  a  marked  feature. 
It  controls  vascular  excitement,  promotes  secretion,  relaxes  spasm, 
and  alleviates  pain.  The  typical  indications  for  it  are  a  full  bound- 
ing pulse,  flushed  countenance,  bright  eyes,  and  contracted  pupils. 
The  delirium  of  gelsemium  is  of  active  character.  In  using  for  its 
sedative  effect,  from  twenty  to  thirty  drops  of  a  saturated  tincture 
of  the  fresh  root  should  be  added  to  four  ounces  of  water,  and  a 
teaspoonful  of  this  administered  every  hour. 

Jaborandi  is  another  sedative  for  sthenic  conditions.  It  controls 
vascular  and  cardiac  excitement,  promotes  secretion,  especially  from 
the  skin,  and  alleviates  muscular  pain.  Its  cooling  influence  upon 
the  skin  imparts  a  grateful  sensation  to  the  fever  patient,  and  modi- 
fies the  exalted  temperature  shortly  after  its  use  is  begun.  In  or- 
der that  the  agent  may  be  reliable  it  must  be  prepared  from  the 
fresh  crude  article;  the  ordinary  fluid  extracts  of  the  market  being 


12  INTRODUCTION. 

comparatively  worthless  for  sedative  purposes.  "When  using,  add 
from  one  to  three  fluidrachms  to  four  ounces  of  water,  and  give  a 
teaspoonfnl  every  hour.  Full,  strong,  hard  pulse,  with  dry  skin  and 
severe  muscular  pain  is  a  special  indication  for  its  use. 

Veratrum  is  also  a  remedy  for  sthenic  febrile  conditions.  It 
sedates  vascular  excitement  of  the  general  circulation,  lowers  an 
Exalted  temperature,  and  promotes  general  secretion.  It  fills  much 
the  ,same  place  as  jaboraudi,  though  it  is  not  as  satisfactory.  Its 
special  indication  is  a  full  hard  pulse,  with  elevation  of  tempera- 
ture. It  is  contraindicated  where  gastric  irritation  is  present  lu 
using,  add  fifteen  or  twenty  drops  of  a  reliable  drug  to  four  ounces 
of  water,  and  give  a  teaspoonful  every  hour. 

Ferric  PJios.  is  Schiissler's  remedy  for  fever,  and  it  often  proves 
reliable,  its  searching  effects  sometimes  becoming  appreciable  after 
the  special  sedatives  have  failed.  It  is  especially  adapted  to  the 
treatment  of  symptomatic  fevers  before  plastic  exudation  begins  in 
the  inflamed  part.  In  using,  add  three  grains  of  the  3x  trituration 
to  four  ounces  of  water,  and  give  a  teaspoonful  every  hour. 

Potassium  Chloride  is  the  remedy  for  symptomatic  fever  after 
plastic  exudation  has  begun,  as  it  promotes  rapid  removal  of  the 
exudate  by  absorption,  thus  preventing  obstructive  organization 
and  destructive  changes.  In  using,  add  five  grains  of  the  3x  tritu- 
ration to  four  ounces  of  water,  and  order  a  teaspoonful  every  hour. 

Adjuvants  may  often  be  employed  with  advantage  to  aid  the 
influence  of  the  special  sedatives.  Prominent  among  these  are  the 
vapor  bath,  cold,  tepid  and  hot  packs  and  baths,  and  various  enemata. 

But  though  the  special  sedatives  answer  an  excellent  purpose  in 
the  treatment  of  non-infectious  and  malarial  fevers,  as  well  as  in 
some  other  mild  infectious  fevers,  such  as  roseola,  measles,  mumps, 
and  chicken-pox,  there  are  others  where  there  are  such  rapid 
destructive  and  septic  changes  in  the  blootfe  and  tissues,  that  they  are 
almost  or  wholly  inefficient.  In  typhoid  fever,  typhus  fever,  yellow 
fever  and  diphtheria,  where  general  necrotic  changes  are  pronounced, 
1  ittle  satisfactory  use  can  be  made  of  them.  We  must  then  depend 
upon  the  antiseptic  sedatives — remedies  which  combine  antiseptic, 
antinecrotic  and  stimulating  properties  with  those  of  a  special  sed- 
ative. Prominent  in  this  class  are  echinacea,  lachesis,  baptisia,  and 
salicylate  of  ammonium. 

Echinacea  is  not  only  an  arterial  sedative, — not  quite  as  markedly 
so  as  the  special  sedatives,  probably, — but  it  controls  necrotic  tenden- 
cies in  the  blood  and  tissues,  both  when  used  locally  and  when  taken 
internally.  It  seems  to  be  an  organizer,  improving  the  vitality  of  the 
circulating  fluids  and  tissues,  fortifying  them  against  septic  and 


FEVER,  13 

necrotic  changes.  In  all  febrile  conditions  where  septic  states  tend- 
ing to  necrosis  of  tissue  arc  common,  as  well  as  where  they  are  actu- 
ally present,  it  commands  the  loading  place  as  a  remedy.  The 
pathology  of  the  disease  in  question  will  afford  the  indications  for 
it — breaking  down  of  the  blood  corpuscles  with  destruction  of  the 
fibrin  element,  and  granular  degeneration  of  the  fixed  cells,  with  lo- 
calized necrosis  of  the  soft  tissues.  This  we  find,  to  great  or  less 
extent,  in  all  severe  infectious  diseases.  The  average  dose  for  an 
adult  is  ten  drops  of  a  saturated  tincture  of  the  recent  plant,  or  its 
equivalent,  repeated  every  hour. 

Lacliesis  comes  nearest  echinacea  in  its  power  over  necrotic  condi- 
tions occurring  in  febrile  diseases.  It  improves  the  power  of  the 
heart  when  this  organ  is  laboring  tinder  the  depressing  influence  of 
toxines,  and  stimulates  the  organs  supplied  by  the  pneumogastric 
nerve  generally.  It  is  especially  indicated  in  infectious  diseases 
attended  by  feeble,  tremulous  heart  induced  by  toxic  causes.  In  fevers 
of  low  form,  where  there  is  marked  prostration  with  phagedenic  tend- 
encies of  the  tissues,  as  in  malignant  scarlatina,  diphtheria,  hemor- 
rhagic  variola,  etc.,  it  is  perhaps  our  best  recourse,  especially  where 
cardiac  failure  portends.  The  6x  trituration  may  be  administered  in 
two-grain  doses  every  two  or  three  hours  in  such  cases. 

Baptisia  is  recommended  in  a  class  of  cases  similar  to  those  in  which 
echinacea  is  so  efficacious.  It  acts  as  a  sedative  and  stimulant  in 
typhoid  conditions,  and  controls  to  some  extent  necrotic  tendencies; 
sloughing  of  tissue  in  the  intestine  in  typhoid  fever,  the  throat  in 
scarlatina  and  diphtheria,  etc.,  responding  to  its  action.  Duskiness  of 
tissue,  prune -juice  discharges  and  low  muttering  delirium  indicate 
it.  We  once  thought  that  we  possessed  the  acme  of  treatment  in  such 
conditions  when  provided  with  this  remedy,  but  there  is  little  doubt 
that  echinacea  far  excels  it  in  any  case  where  it  is  adapted.  From 
two  to  ten  drops  of  the  saturated  tincture  of  the  fresh  root  or  its 
equivalent,  may  be  administered  every  hour  or  two  in  cases  requir- 
ing it 

Scdicylate  of  ammonium  is  an  antiseptic  sedative  of  rare  virtue  where 
a  persistently  high  temperature  renders  a  case  of  infectious  fever 
especially  serious.  When  other  remedies  fail  in  such  cases  we  may 
safely  depend  upon  this  agent  to  reduce  the  temperature,  and  it  is 
an  antiseptic  of  excellent  service  at  the  same  time.  Full  directions 
for  preparing,  dose,  etc.,  can  be  found  in  "Dynamical  Therapeutics." 

Another  class  of  remedies,  which  I  shall  here  term  correctives, 
fulfills  important  indications  in  fever  on  many  occasions.  The  action 
of  these  remedies  is  chemico-vital  in  nature  perhaps,  the  result 
tending  toward  the  correction  of  excessive  acidity  or  alkalinity. 


14  INTRODUCTION. 

They  can  hardly  be  considered  as  antiseptics,  but  they  correct  condi- 
tions which  materially  interfere  with  the  proper  action  of  remedies 
generally.  Three  important  remedies  of  this  class  are  sulphite  of 
sodium,  sulphurous  Nacid,  and  hydrochloric  acid. 

Sulphite  of  sodium  is  a  corrective  where  there  is  a  heavily  loaded 
tongue,  presenting  a  pasty-white  appearance,  with  pallid  mucous  mem- 
braue.  This  indicates  excessive  alkalinity  of  the  system,  and  a  salt 
of  sodium  is  the  natural  corrective.  Before  we  can  reasonably  expect 
other  remedies  to  produce  their  ordinary  effects  this  must  be  corrected. 
A  few  days  of  sulphite  of  sodium  will  accomplish  this,  and  all  other 
aggravated  symptoms  will  be  correspondingly  modified.  The  sulphite 
may  be  administered  in  one-  or  two-grain  doses  every  three  or  four 
hours  during  the  day,  until  the  morbid  condition  of  the  tongue  calling 
for  it  has  disappeared,  which  will  usually  be  within  three  or  four 
days.  It  is  advisable  to  administer  the  remedy  in  capsules,  where 
swallowing  is  readily  accomplished. 

Sulphurous  acid  is  a  corrective  where  the  tongue  is  coated  brown, 
with  dark  sordes  on  the  teeth  and  lips,  or  even  without  these  accom- 
paniments. Under  this  coating  the  mucous  membrane  is  darker  red 
than  is  natural,  it  usually  being  uncovered  at  the  sides  and  tip.  Low 
forms  of  fever  often  present  us  with  this  condition,  and  sulphurous 
acid  is  then  an  appropriate  remedy.  Twenty  drops  of  the  acid,  well 
diluted  in  water,  may  be  given  every  three  or  four  hours. 

Hydrochloric  acid  is  the  corrective  where  the  tongue  is  red,  slick, 
and  shining,  presenting  a  beefsteak  appearance.  Probably  there  is 
a  lack  of  acid  in  the  system  in  these  cases,  as  acids  seem  to  help  lag- 
ging cases  immediately  where  the  indication  is  marked.  Fifteen  or 
twenty  drops  of  dilute  hydrochloric  acid,  in  syrup,  may  be  adminis- 
tered in  such  cases  every  four  hours,  to  prepare  the  way  for  other 
remedies. 

The  subject  of  antiperiodics  demands  a  little  space.  There  are 
certain  fevers  characterized  by  marked  periodicity  which  seems  to  be 
the  leading  feature  of  the  attack,  and  which  must  be  interrupted 
before  much  progress  can  be  made  toward  a  cure.  There  are  those  who 
even  argue  that  the  cure  is  completed  when  the  periodicity  is  inter- 
rupted ;  but  this  is  a  mistaken  idea,  for  the  physician  who  expects  to 
cure  malarial  attacks  with  quinine  or  other  antiperiodics  will  find  him- 
self disappointed  in  a  majority  of  the  cases  treated.  Quinine  and 
other  antiperiodics — notably  quinine — interrupt  periodicity,  but  do 
not  remove  the  materies  morbi  from  the  system,  and  the  periodical 
manifestation  returns  after  a  cycle,  or  multiple  of  cycle,  of  seven  days. 

While  antiperiodics,  then,  are  important  remedies  to  interrupt 
marked  periodicity  where  the  cause  arises  from  malarial  influence, 


FEVER.  15 

curative  effects  can  not  be  expected  from  them  usually,  and  rational 
means  applied  to  the  morbid  conditions  existing  must  follow  their  use 
if  permanent  benefit  is  to  be  insured.  Quinine  is  the  ideal  antiperiodic, 
and  the  one  which  is  usually  employed.  But,  unfortunately,  it  is  not 
always  a  remedy  which  can  be  administered  without  objectionable 
results.  When  administered  to  certain  patients  it  produces  ringing  in 
the  ears,  nervous  irritability,  and  even  delirium,  aggravating  already- 
existing  evils  instead  of  benefiting  them.  The  proper  time  for  the 
administration  of  quinia  is  during  the  intermission  or  remission  of  per- 
iodical diseases,  and  the  system  should  be  prepared  for  its  use  by  the 
previous  administration  of  such  remedies  as  render  the  tongue  moist 
and  cleaning,  the  pulse  soft  and  open,  and  place  the  nervous  system 
in  a  condition  of  tolerance.  This  can  frequently  be  accomplished  by 
the  use  of  the  special  sedatives,  selected  as  already  suggested.  Qui- 
nine is  of  little  use  in  the  treatment  of  infectious  fevers  caused  by 
bacteria.  It  seems  to  disturb  the  patient  and  aggravate  the  symptoms, 
in  the  majority  of  cases.  Its  principal  place  is  in  the  treatment  of 
malarial  couditions,  and  here  we  only  rely  upon  it  to  interrupt  the 
periodicity. 

There  are  other  antiperiodics  which  sometimes  excel  quinine  in 
certain  respects,  and  are  worthy  of  notice  in  this  place : 

Arseniatc  of  quinia,  3x  trituration,  is  not  usually  as  active  as  qui- 
nine, but  it  is  sometimes  more  efficacious,  and  is  less  unpleasant  for 
children  and  sensitive  adults.  It  is  better  adapted  for  steady  admin- 
istration in  chronic  cases,  as  it  does  not  leave  behind  the  objection- 
able effects  of  quinine  upon  prolonged  use. 

AUtonia  should  also  be  recollected  where  stubborn  cases  of  perio- 
dicity are  met,  for  it  will  repay  careful  study  aud  trial.  It  is  recom- 
mended in  malarial  cachexia  where  the  tongue  is  coated  and  the  urine 
loaded  with  phosphates.  It  seems  more  permanent  in  its  effects 
than  quinine,  though  slower  in  action. 

Faradism,  the  "tonic  treatment"  being  employed,  is  not  to  be 
forgotten  in  the  treatment  of  chronic  periodicity.  When  assisted  by 
cabinet  vapor  baths  it  is  almost  invincible. 

The  use  of  stimulating  tonics  during  convalescence  should  have 
gone  out  of  fashion  long  ago.  Such  drugs  as  strychnia,  nux  vomica, 
calisaya,  quinia,  etc.,  tend  to  derange  digestion,  set  the  nervous  sys- 
tem on  edge,  aud  thus  oppose  recuperative  processes.  Such  agents 
may  be  of  some  service  in  preventing  the  return  of  malarial  attacks, 
but  are  usually  objectionable  during  convalescence  from  other  infec- 
tious fevers. 

Undue  muscular  exertion  should  be  avoided  during  convalescence, 
the  patient  being  prohibited  from  rising  from  bed  before  the  weak- 


16  INTRODUCTION. 

ened  condition  of  the  heart-muscle  and  degenerated  tissues  gener- 
ally has  been  corrected.  The  food  should  be  selected  with  care 
during  this  time,  and  adapted  to  the  particular  condition  which  may 
have  been  brought  about  by  the  morbid  action  preceding.  After 
typhoid  fever  and  certain  other  diseases  the  alimentary  mucous 
membrane  is  in  a  debilitated  condition  for  several  weeks,  and  the 
return  to  ordinary  diet  should  be  gradual,  the  food  being  selected 
with  due  regard  to  this  fact  After  all  cases  of  protracted  infectious 
disease  the  digestive  apparatus  is  weakened,  and  recuperates  slowly, 
and  there  is  great  danger  in  the  early  use  of  crude  aud  indigestible 
food  soon  after  convalescence.  Diphtheria  is  an  affection  in  which 
collapse  and  death  have  followed  injudicious  feeding  early  after  con- 
valescence ;  and  this  danger  arises  in  every  case  of  severe  infectious 
disease. 

The  abuse  of  opiates  in  favors  in  past  years  has  been  a  matter  of 
common  record.  Even  our  old  Eclectics  cannot  plead  innocence  in 
this  direction,  as  their  favorite  remedy  for  febrile  conditions  was  for- 
merly the  diaphoretic  powder,  containing  enough  opium  to  disturb 
the  nervous  system  unpleasantly,  in  many  instances.  There  are 
few  febrile  conditions  where  opium  or  its  alkaloids  can  be  used  suc- 
cessfully Doubtless,  in  many  cases,  life  has  been  sacrificed  by  the 
stupid  administration  of  this  drug.  The  practice  of  old,  with  its 
crudities,  could  recognize  but  one  remedy  for  restlessness  and  pain, 
and  that  was  some  form  of  opium ;  and  as  such  symptoms  were  com- 
mon, it  entered  largely  into  the  ordinary  treatment  of  fevers.  It 
excites  the  brain  and  nervous  centers  generally,  arrests  secretion 
and  paralyzes  function,  with  resulting  debility  after  the  narcotic 
effect  has  passed  off  Delirium,  increase  of  pyrexia,  dryness  of  the 
tongue  and  skin,  with  diminished  urinary  excretion,  follow  its  use, 
while  enough  of  the  drug  to  cause  slumber  in  the  wakeful  and  rest- 
less fever-subject  is  liable  to  produce  profound  prostration.  Its 
occasional  use  may  be  allowable,  but  its  objectionable  features  as 
a  drug  for  common  use  should  be  fully  realized.  Unfortunately, 
it  has  been  superseded,  to  some  extent,  by  a  class  of  drugs — the 
coal-tar  products — which  may  leave  behind  extreme  prostration  and 
cardiac  debility,  from  which  recovery  is  slow  and  difficult.  Our 
materia  medica  contains  numerous  safe  resources  for  the  relief  of 
such  symptoms  as  those  for  which  these  drugs  are  prescribed  in 
fevers,  as  every  diligent  and  observing  practitioner  must  know. 
Opium  may  be  administered  cautiously  where  the  skin  is  not  dry, 
where  the  pulse  is  soft  and  open  (not  hard  or  wiry),  where  the 
tongue  is  moist  and  normal  in  shape  (not  dry  and  contracted,  nor 
reddened  and  pointed  at  the  tip),  and  where  the  nervous  system  is 


INFLAMMATION.  17 

not  markedly  disturbed.  Of  course  there  are  extreme  cases  where 
all  indications  may  be  disregarded  and  lethal  doses  of  opiates  admin- 
istered, these  being  hopeless,  and  attended  by  excruciating  pain. 

Muscular  pain,  where  opiates  were  once  employed  so  extensively, 
and  where  the  coal-tar  derivatives  are  now  administered  too  fre- 
quently, is  a  common  symptom  of  many  fevers.  When  rheumatoid  in 
character,  as  it  often  seems,  it  may  usually  be  alleviated  by  the  use 
of  organic  remedies  which  leave  no  ill-effect  behind.  Among  these 
may  be  mentioned  rhamnus  californica,  especially  valuable  where 
a  laxative  effect  is  desirable;  cimicifuga;  caulophyllum ;  bryonia, 
when  the  pain  is  principally  about  the  thorax.  Salicylic  acid  from 
wintergreen,  and  salicylate  of  sodium  may  be  of  service.  And  some- 
times phenacetin — one  of  the  least  objectionable  of ""  the  coal-tar 
products — will  be  found  to  answer  the  best  purpose.  However,  it 
should  be  recollected  that  the  muscular  pains  which  attend  cerebro- 
spinal  fever  and  some  other  affections  depend  upon  localized  irrita- 
tion of  nervous  structure,  which  must  be  removed  before  muscular 
pain  can  be  controlled  with  these  remedies.  Here,  the  local  nervous 
lesion  will  demand  first  attention. 

Cathartics,  which  were  once  supposed  to  exert  an  important  influ- 
ence in  the  treatment  af  fevers,  are  used  but  little  by  modern 
practitioners.  The  idea  that  febrile  excitement  can  be  materially 
lessened  by  their  action  now  receives  little  credence.  There  is  no 
doubt  that  such  drugs  disturb  and  irritate  the  intestinal  mucosa,  in- 
terfering with  digestion  and  assimilation;  and  when  it  is  recollected 
that  the  alimentary  canal  is  not  an  excretory  apparatus,  and 
that  there  is  a  tendency  toward  structural  degeneration  here  in 
most  fevers,  the  common  use  of  cathartics  in  their  treatment  seems 
extremely  irrational. 

H.    INFLAMMATION. 

Synonyms. — Phleginone;  Phlogosis;  Phlegmasia;  eta 
Definition. — A  localized  disturbance  of  cellular  and  vascular 
function,  of  destructive  tendency,  characterized  by  hypersemia,  exuda- 
tion of  blood-  and  tissue-elements,  and  migration  of  leucocytes, 
attended  by  pain,  heat,  redness,  swelling  and  impairment  of  function 
in  the  part  affected. 

Etiology. — The  causes  of  inflammation  are  local  irritants,  which 
may  be  divided  into  two  general  classes,  viz.,  simple  and  infectious. 
Simple  causes  are  those  which  are  non-infectious.  They  comprise 
mechanical  injuries ;  chemical  effects,  such  as  the  action  of  caustics ; 
extreme  congestion  due  to  sudden  arrest  of  secretion;  etc.  Infec- 
tious causes  comprise  numerous  varieties  of  microorganisms,  some 


18  INTRODUCTION. 

of  which  have  been  separated,  cultivated  and  studied,  and  some  of 
which  exist  at  present  only  in  imagination.  At  least,  their  presence 
has  not  yet  been  satisfactorily  demonstrated.  However,  there  are 
extremists  who  assert  that  all  true  inflammatory  action  depends 
upon  the  presence  of  microorganisms  in  the  affected  tissues. 

Infective  inflammation  may  probably  arise  either  from  the  direct 
action  of  the  microbes  upon  the  tissues,  from  the  irritation  of  their 
toxines,  or,  as  is  usually  the  case  doubtless,  from  a  combination  of 
these  influences. 

Pathology. — The  pathology  of  inflammation  is  so  complicated 
that  a  separate  study  of  some  of  its  essential  features  will  be  most 
likely  to  convey  a  clear  conception  of  the  nature  of  the  disease.  We 
will  therefor*  consider  in  the  beginning  the  principal  histological 
elements  concerned. 

HISTOLOGICAL   ELEMENTS    INVOLVED. 

Blood-vessels.  The  principal  vascular  changes  of  inflammation 
occur  in  the  capillaries,  though  the  minute  veins  participate. 
Through  the  walls  of  these  vessels  the  blood-elements  make  thier 
escape,  and  through  them  the  exudate  largely  enters  the  circulation 
after  the  inflammatory  action  has  subsided.  The  walls  of  the  capil- 
laries consist  of  a  single  layer  of  nucleated  endothelial  cells,  united 
by  an  interstitial  cement -substance.  Inflammatory  action  disinte- 
grates the  interstitial  substance  at  various  points,  and  openings  (sto- 
mata)  are  left  between  the  edges  of  the  cells,  through  which  the 
inflammatory  exudation  makes  its  escape.  Mechanical  and  chemical 
influences  doubtless  conspire  to  bring  about  this  con- 
dition. The  engorgement  of  the  vessels  gives  rise  to 
distension  and  intravascular  pressure,  and  the  large 
volume  of  blood  in  the  part  increases  the  heat,  this 
combination  of  forces  soon  resulting  in  defective 
points  in  the  cement-substance,  where  stomata  after- 
wards appear. 

MA<;-  There  seems  to  be  an  excitement  in  even  the  most 
minute  blood-vessels  which  suggests  a  nervous  stimulus.  The  arteri- 
oles  pulsate  tumultuously,  and  the  entire  inflamed  part  is  filled  with 
a  throbbing  sensation,  probably  due  to  vascular  excitement  and  nerv- 
ous erethism.  The  developmental  and  nutritional  properties  of 
these  organs  are  also  evidently  disturbed,  as  evidenced  by  the  fact 
that  vascular  tufts  may  be  developed  during  inflammation  in  such 
non-vascular  structures  as  the  cornea;  and  new  capillary  loops  are 
occasionally  put  forth  exuberantly  in  other  tissues. 

Tluc,  Blood-corpuscles.  Three  kinds  of  blood-corpuscles  exist,  and 
all  are  concerned  in  inflammatory  action.  These  are  (1)  the  white 


INFLAMMATION.  19 

corpuscles,  (2)  the  red  corpuscles,  and  (3)  the  blood-plaques  or  third 
corpuscles.  The  accompanying  diagram  is  suggestive  of  the  rela- 
tionship which  these  sustain  to  the  circulation.  The  globular  bod- 
ies near  the  wall  of  the  vessel  are  white  cor- 
puscles, the  oblong  figures  accompanying  them 
suggest  the  third  corpuscles,  though  these  are 
not  readily  visible  in  circulating  blood,  and 


the  dark  central  baud  of  disks  the  red  corpuscles.  The  white  cor- 
puscles, being  of  lower  specific  gravity  than  the  red,  are  crowded 
out  of  the  center  of  the  current,  and  move  along  the  periphery. 

The  white  corpuscles  take  the  most  active  part  in  the  process  of 
inflammation.  They  possess  the  power  of  spontaneous  motion,  and 
leave  the  capillaries  and  veins  at  an  early  period,  migrating  by  amoe- 
boid motion  through  the  connective  tissue,  there  being  adapted  to 
a  variety  of  functions.  Leucocytes  are  continually  undergoing 
change  of  form,  their  locomotion  being  due  to 
this  property.  Infolding  processes  enable  them 
to  take  up  floating  particles  and  inclose  them  in 
their  substance.  How  these  foreign  particles  are 
afterward  disposed  of  does  not  seem  very  clear. 
Possibly  pathogenic  microbes  are  aimlessly  dis» 

FOBMS  OF  A  SINGLE  LEUCO-  •>    r  J 

M™EOT!SSEKVED  WITHIN  TEN  tributed  through  the  tissues  and  blood-vessels, 
other  debris  being  scattered  along  iu  much  the  promiscuous  manner 
in  which  it  is  taken  up.  Doubtless  the  leucocytes  exert  a  solvent 
or  digestive  influence  upon  certain  substances  incorporated.  Leuco- 
cytes should  not  be  confounded  with  embryonal  connective-tissue  cells, 
which  are  at  first  detached,  possess  the  power  of  amoeboid  motion, 
and  resemble  them  very  closely  morphologically,  but  differ,  from 
the  fact  that  they  may  become  fixed  tissue-cells  at  a  later  period, 
and  assist  in  the  repair  of  damaged  structure,  or  play  a  very  mis- 
chievous part  in  interstitial  inflammation. 

A  leucocyte  consists  of  a  hyaline  mass  contained  in  the  meshes  of 
a  reticulum  of  protoplasmic  fibers  and  containing  a  nucleus.  The 
nucleus  and  reticulum  constitute  important  parts  of  the  structure, 
and  are  broken  up  during  degeneration  into  a  pus-corpuscle. 

The  destination  of  a  migrating  leucocyte  during  inflammation  is 
uncertain.  If  the  inflammatory  action  be  slight  and  terminate  in 
resolution,  it  usually  assists  in  clearing  up  the  affected  area  and  then 
returns  to  the  circulation,  either  directly,  through  a  stoma,  or  by  way 
of  the  lymphatics.  Where  the  inflammatory  action  is  more  severe  and 
there  is  considerable  destruction  of  tissue,  its  substance  may  con- 
tribute to  the  growth  of  embryonal  tissue-cells  (after  deliquescence). 
In  another  instance  it  may  be  converted  into  a  pus-corpuscle. 


20  INTRODUCTION. 

The  red  corpuscles  are  too  well  known  to  require  description. 
Possessing  no  power  of  spontaneous  motion,  their  passage  through 
the  walls  of  the  blood-vessels  is  wholly  a  passive  process,  due  to  a 
damaged  condition  of  the  vascular  walls  and  engorgement  of  the 
vessels.  The  number  of  red  corpuscles  outsidn  the  blood-vessels  in 
an  inflamed  area  will  suggest  a  relative  amount  of  disturbance  of  this 
character.  Being  intimately  connected  with  the  production  of  ani- 
mal heat,  it  is  more  than  probable  that  the  abnormal  elevation  of 
temperature  observed  in  inflamed  areas  is  due  to  the  increased 
number  of  red  corpuscles  present.  The  same  observation  applies  to 
the  redness  observed  in  an  inflamed  part,  increased  quantity  of  arte- 
rial blood  imparting  the  heightened  color.  Being  incapable  of 
amoeboid  motion,  the  red  corpuscles  are  not  such  common  carriers 
of  pathogenic  germs  as  white  corpuscles,  and  as  they  do  not  return 
to  the  general  circulation  after  diapedesis,  they  probably  exert  little 
influence  in  the  spread  of  infection.  After  the  inflammation  has  sub- 
sided they  become  broken  up,  and  the  detritus  is  absorbed. 

The  third  corpuscles  are  small  colorless  spheres  or  granules, 
twenty  times  as  numerous  as  the  red  corpuscles.  They  probably 
represent  the  fibrin-element  of  the  blood ;  and  it  is  likely  that  they 
exude  from  the  vessels  during  inflammation  and  constitute  the  prin- 
cipal bulk  of  the  fibrin  found  in  inflamed  tissues. 

Fixed-tissue  Cells.  The  fixed-tissue  cells  participate  in  the 
histological  changes  of  inflammation.  Where  the  inflammatory 
action  is  severe,  death  of  a  community  of  these  cells  may  occur  in 
the  center  of  the  affected  area,  a  mass  of  necrosed  tissue  marking 
the  site.  This  is  observed  upon  a  small  scale  in  a  common  boil 
(furunculus),  and  upon  a  larger,  in  phlegmonous  inflammation.  The 
direct  cause  of  this  necrotic  influence  is  not  yet  satisfactorily  settled. 
Radical  believers  in  the  doctrine  that  all  clinical  inflammation  is 
microbic  in  origin,  ascribe  the  condition  to  either  the  direct 
action  of  microorganisms,  or  to  powerful  toxines  generated  by  them, 
except  where  starvation  of  the  cells  occurs  from  strangulation  of 
their  blood-supply.  But,  as  it  is  generally  admitted  that  chemico- 
vital  influences  are  largely  concerned  in  the  destruction  of  the 
interstitial  cement  in  the  capillaries  whereby  these  vessels  become 
permeable  by  the  blood,  it  might  not  be  unreasonable  to  ascribe 
destruction  of  fixed-tissue  cells  to  a  similar  influence,  occasionally,  at 
least.  In  chronic  inflammation,  instead  of  destruction  of  fixed- 
tissue  cells,  as  in  acute  inflammation,  there  is  proliferation  of  these 
elements,  these  furnishing  the  bulk  of  the  inflammatory  product, 
instead  of  exudation.  This  process,  though  not  immediately  destruc- 
tive, may  give  rise  to  extremely  serious  results,  by  impairing  the 


INFLAMMATION.  21 

functions  of  such  vital  organs  as  the  liver  and  lungs.  In  intersti- 
tial hepatitis  (cirrhosis)  and  interstitial  pneumonia,  proliferation  of 
connective-tissue  cells  is  almost  invariably  attended,  sooner  or  later, 
by  fatal  results. 

Exudation.  The  exudation  which  occurs  in  inflammation  con- 
sists of  solid  and  liquid  parts.  The  solid  parts  are  represented  by 
the  blood-corpuscles,  which  have  already  been  considered.  The 
liquid  part,  which  consists  of  blood-plasma,  is  termed  the  inflamma- 
tory translation. 

This  accompanies  the  corpuscles  in  their  passage  through  the 
openings  in  the  vessels  caused  by  the  damage  to  the  vascular  walls, 
its  escape  being  due  to  the  vis  a  tergo  and  the  porosity  of  the  vas- 
cular structures.  The  swelling  which  attends  acute  inflammation  is 
largely  due  to  the  inflammatory  transudation,  the  amount  in  the 
affected  tissues  determining  the  extent  of  the  tumefaction.  The 
oedema  which  attends  certain  inflammatory  conditions  is  the  result 
of  excessive  transudation.  This  is  likely  to  occur  when  parts 
freely  supplied  with  connective  tissue  are  involved,  such  as  the  deep 
muscular  tissues,  the  lungs,  the  eyelids,  scrotum,  etc.  Where  the 
parts  are  firm  and  there  is  little  connective  tissue,  there  is  but  small 
amount  of  inflammatory  transudation.  After  inflammation  subsides, 
the  transudation  is  removed  by  absorption  unless  suppuration  occur, 
in  which  case  it  becomes  the  pus-serum. 

Where  deep-seated  inflammation  occurs,  the  exudation  is  poured 
out  into  the  cellullar  tissue  and  lymph  spaces,  where  the  various 
changes  already  described  are  carried  on.  This  may  be  interstitial,  or 
parenchymaious  inflammation.  When  acute,  the  exudation  is  increased 
by  the  addition  of  liquid  elements  from  the  tissue-cells.  In  suppura- 
tive  inflammation,  either  a  part  or  the  whole  of  the  exudation 
is  transformed  into  pus.  The  blood-corpuscles,  as  well  as  many  of 
the  fixed-tissue  cells,  become  pus-corpuscles.  Hemorrhagic  inflam- 
mation is  characterized  by  the  presence  of  an  excessive  number  of 
.red  corpuscles  in  the  exudation.  In  most  cases  of  inflammation 
a  few  red  corpuscles  escape  from  the  blood-vessels,  but  in  this 
instance  enough  are  poured  out  to  constitute  actual  hemorrhage, 
the  exudation  presenting  a  reddened  appearance  suggestive  of  the 
condition.  Such  cases  are  attended  either  by  serious  local  or  general 
lesions.  A  very  high  grade  of  inflammatory  action  may  prove  suf- 
ficiently destructive  to  the  blood-vessels  to  bring  about  this  result 
Depravity  of  tissue  from  previous  disease,  or  serious  obstruction  to 
the  general  circulation,  as  in  valvular  disease  of  the  heart,  chronic 
nephritis,  hepatic  cirrhosis,  etc.,  dispose  to  such  condition,  as  well 
as  syphilitic  and  erysipelatous  complications. 

Usually,  in  inflammation   of  serous  membranes,  the  exudation  is 


22  INTRODUCTION 

poured  out  upon  the  surface,  and  the  leucocytes  and  third  corpuscles 
are  here  destroyed,  the  combination  of  the  fibrin  ferment,  debris  from 
the  leucocytes,  and  blood-plasma  forming  fibrin,  constituting  a  thick 
layer  of  coagulable  material,  which  becomes  firmly  welded  to  the 
serous  surface  by  means  of  capillary  blood-vessels  and  granulations, 
these  sprouting  up  and  growing  into  it.  This  forms  a  nidus  or  hot-bed 
for  the  proliferation  of  connective-tissue  cells,  and  as  the  endothe- 
lium  participates  actively  in  the  inflammatory  changes,  perforations 
occur,  through  which  embryonal  connective-tissue  cells  wander,  to 
undergo  rapid  multiplication  and  organization,  until  the  exudation 
is  entirely  removed  and  replaced  by  connective  tissue.  If  opposing 
surfaces — such  as  the  reflections  of  the  pleura  or  peritoneum — are 
involved,  entire  serous  sacs  may  thus  be  obliterated,  a  growth  of  new 
connective  tissue  completely  bridging  the  chasm.  If,  on  the  other 
hand,  the  endothelial  cells  remain  intact,  no  embryonal  connective- 
tissue  cells  are  liberated,  and  the  exudation  is  absorbed,  leaving  the 
serous  surface  free.  If  a  serous  inflammation  be  severe  enough  to 
result  in  suppuration,  the  leucocytes  and  embryonal  cells  become 
converted  into  pus-corpuscles,  and  collections  of  pus,  such  as  empy- 
ema,  pyocardium,  and  purulent  peritonitis,  result.  Where  the  trans- 
udation  is  largely  in  excess  of  the  corpuscular  elements  of  the  exuda- 
tion, the  inflammation  runs  a  sub-acute  course,  and  results  in  the 
accumulation  of  a  considerable  quantity  of  serous  fluid  in  the  cavity. 

When  mucous  membranes  are  involved,  the  mucous  follicles  secrete 
profusely  in  most  instances,  flushing  away  the  exudation  which 
is  thrown  out  upon  the  surface,  and  constituting  catarrhal  inflamma- 
tion. At  a  later  stage,  the  leucocytes  and  embryonal  cells  become 
converted  into  pus-corpuscles,  and  these  mix  with  the  mucus  to 
form  a  muco-purulcnt  discharge.  In  croupous  inflammation,  the  fibrin- 
element  predominates,  and  a  coagulum  which  resists  the  flushing 
influence  of  the  catarrhal  discharge  is  formed,  and  this  coagulum 
becomes  more  or  less  firmly  attached  to  the  mucous-epithelium,  the 
cells  of  which  undergo  a  process  of  necrosis.  Thus  is  formed, 
the  pseudo-  or  false-membrane.  When  the  necrosis  of  the  mucous 
membrane  is  only  slight,  the  secretion  of  the  mucous  follicles 
beneath  the  exudation  may  suffice  to  lift  it  away;  in  more  severe 
cases, — as  in  diphtheria,  for  example, — the  entire  mucous  membrane 
is  involved  in  the  necrosis,  and  the  separation  involves  a  slower  pro- 
cess of  sloughing. 

In  catarrhal  inflammation  of  mucous  membranes,  thickening  may 
occur  from  inflammatory  induration  of  the  submucous  tissue  follow- 
ing organization  of  the  exudation.  The  large  amount  of  fibrous 
material  thus  developed  causes  contraction,  which,  in  tubular  organs, 
may  amount  to  permanent  stricture. 


INFLAMMATION. 


23 


PHENOMENAL  HISTOLOGICAL  CHANGES  OCCURRING  DUBING  INFLAMMATION. 

When  iuflammation  occurs  in  thin,  transparent,  vascular  struc- 
tures, such  as  the  web  of  a  frog's  foot,  tongue,  mesentery,  bladder, 
etc.,  and  the  part  is  properly  placed  under  a  microscope  of  the 
requisite  power,  some  of  the  histological  phenomena  presented  may 
be  seen  and  studied.  After  the  part  has  been  properly  placed  and 
secured,  iuflammation  is  excited  by  the  action  of  some  irritant,  usu- 
ally a  caustic,  like  the  point  of  a  red-hot  needle,  croton  oil,  nitrate 
of  silver,  or  some  similar  irritant  to  animal  tissues,  and  an  excita- 
tion in  the  minute  bloodvessels  in  an  area  surrounding  this  point  is 
soon  observable. 

If  the  normal  condition  of  the  blood-vessels  is  carefully  noted 
before  the  irritant  is  applied,  a  striking  change  will  be  apparent 
after  the  inflammatory  action  has  become  fully  developed.  In  the 
__  normal  condition,  the  red  cor- 
puscles remain  in  the  center  of 

the  vessel,  the  surrounding  space 

being  occupied  by  clear  plasma, 

in  which  an  occasional  leucocyte 

is  seen,  moving  leisurely  along 

the  vascular  wall.     The  minute 

capillaries  contain  few  if  any  red 

corpuscles,  and  the  stream  in  all 

the  vessels  moves  along  evenly 
NORMAL  CIRCULATION,  and  steadily,  as  attested  by  the 
behavior  of  the  corpuscles.  The  first  change  in  S 
the  vessels  is  that  of  contraction,  probably  a  reflex  action  due  to 
the  stimulating  influence  of  the  local  irritation.  Soon,  however,  the 
vessels  become  dilated,  and  it  is  seen  that  the  corpuscles  are  hurry- 
ing along  with  increased  momentum.  The  red  corpuscles  increase 
in  number  rapidly,  encroaching  upon  the  space  normally  occupied 
by  plasma  and  leucocytes.  At  first,  the  corpuscles  hurry  through 
the  part  as  well  as  toward  it,  there  being  a  largely  increased  amount 
of  blood  in  motion  toward,  passing  through,  and  moving  away  from 
the  affected  area  (active  hyperaemia).  But  after  a  time  a  slowing  of 
the  current  becomes  noticeable.  The  leucocytes  now  become  promi- 
nent factors.  Large  numbers  of  them  leave  the  axial  current  and 
join  the  slower  procession  along  the  walls  of  the  small  veins  and  cap- 
illaries, showing  more  and  more  of  a  tendency  meanwhile  to  adhere 
and  remain  fixed  to  the  inner  suri'ace  of  the  vessel.  Though  the 
current  may  sweep  them  away  again  and  again,  they  manifest  a  per- 
sistent tendency  to  return  and  adhere  to  the  vascular  wall.  Finally, 
the  entire  inner  wall  of  the  small  veins  becomes  paved  with  them, 


24  INTRODUCTION. 

and  they  seem  piled  upon  one  another  in  heaps,  obstructing  the 
lumen  of  the  vessels  in  some  places,  causing  complete  arrest  of  the 
current  (stasis).  Careful  inspection  will  now  enable  the  observer 
to  discover  the  fact  that  many  of  the  leucocytes  are  passing,  by  amoe- 
boid movement,  through  the  attenuated  and  damaged  walls  of  the 
veins  and  capillaries.  Some  may  be  found  just  beginning  the  transit 
by  sending  a  narrow  prolongation  through,  while  the  bulk  of  the 
corpuscle  is  still  within  the  vessel.  Others  may  be  found  well  on 
the  way,  a  portion  of  each  lying  outside  the  vessel  and  a  por- 
tion within  it,  the  part  engaged  in  the  vascular  wall  being  marked  by  a 
pronounced  constriction,  while  others  will  be  found  wholly  outside 
the  vessels  in  the  connective  tissue. 

To  summarize,  then,  microscopical  observation  of  a  transparent 
membrane  with  inflammatory  engorgement,  will  enable  one  to  detect 
increased  rapidity  of  the  blood-current  with  subsequent  retardation, 
dilatation  and  increased  tortuosity  of  the  minute  vessels,  migration 
of  leucocytes  (see  illustration),  diapedesis  of  red  corpuscles,  altera- 
tion of  fixedtissue-cells,  etc. 

The  changes  in  the  circulation  of  the  inflamed  area  vary  in  pro- 
portion to  the  position  occupied  in  relation  to  the  central  point  of 
irritation.  At  a  considerable  distance  from  the  place  of  injury  the 
circulation  may  still  be  normal.  Nearer,  the  blood-vessels  are 
dilated  and  the  stream  moves  more  slowly;  still  nearer  is  a  zone  in 
which  there  has  been  free  emigration  of  leucocytes;  and,  when  we 
reach  the  immediate  neighborhood  of  the  point  of  injury,  the  blood  no 
longer  flows  through  the  vessels  but  remains  stagnant,  complete 
stasis  having  resulted.  The  meshes  of  the  surrounding  tissues  are 
swollen,  being  distended  by  coagulable  lymph,  and  the  connective- 
tissue  fibers  are  enlarged  and  softened.  The  epithelial  cells  of 
affected  organs  are  swollen,  their  protoplasm  is  granular  and  more 
opaque,  and  fatty  granules  are  frequently  contained  in  them.  Pro- 
liferation of  new  tissue  gives  rise  to  amoeboid  embryonal  cells, 
which  mingle  with  the  leucocytes  and  red  corpuscles  that  have 
exuded  from  the  vessels.  In  many  cases  of  inflammation,  microbes 
play  an  important  part,  and  are  found  in  the  leucocytes  and  red 
corpuscles,  as  well  as  in  the  plasma. 

Cornea  and  Cartilage  contain  no  blood-vessels,  and,  consequently, 
the  vascular  changes  which  are  noted  in  other  tissues  are  not  observ- 
able, though  in  the  case  of  inflammation  of  the  cornea  it  will  be 
noticed  that  vascular  loops  may  spring  from  the  sclerotic  vessels 
and  invade  the  plasma-channels,  this  being  the  result  of  inflamma- 
tory stimulation. 

One  of  the  first  microscopical  phenomena  of  corneal  inflammation 


INFLAMMATION  25 

is  the  appearance  of  migrating  leucocytes  in  the  plasma-channels, 
which  are  found  in  great  numbers,  packing  the  passages  and  moving 
toward  the  point  of  irritation.  Simultaneously,  the  fluid  contents  of 
the  spaces  are  increased  in  quantity,  the  spaces  being  distended 
and  the  cornea  swollen,  the  tissue-cells  becoming  softened  and 
opaque.  The  infiltration  results  from  fluid  supplied  partly  by  adja- 
cent blood-vessels,  and  partly  from  the  tissue-cells  of  the  affected 
structure.  Vascular  loops  spring  up  from  the  sclerotic  vessels  at  the 
periphery,  and  follow  the  leucocytes  along  the  plasma-channels. 
Sometimes  these  become  so  prominent  as  to  constitute  what  is  known 
as  pannus. 

Cartilage  possesses  no  circulating  channels  in  its  structure,  its 
circulation  being  carried  on  by  cellular  diffusion,  solely.  Conse- 
quently, active  inflammatory  action  does  not  occur,  chondritis  being 
a  chronic  process.  The  principal  changes  which  occur  early,  there- 
fore, can  only  be  noticed  as  changes  in  the  cartilage  cells,  which 
undergo  enlargement,  softening,  and  degeneration.  After  long-con- 
tinued inflammation  of  cartilage,  however,  new  vessels  may  grow 
over  the  affected  surface,  and  even  penetrate  the  substance  of  the  car- 
tilage and  grow  in  the  direction  of  the  inflammatory  focus,  similarly 
to  the  vascular  phenomenon  presented  in  paunus. 

Phagocytosis  is  a  term  applied  by  Metschnikoff  to  a  destructive 
process  supposed,  by  him,  to  be  exerted  upon  microbes  by  leucocytes 
and  certain  fixed  tissue-cells,  such 
as  mucous  corpuscles,  connective- 
tissue  cells,    endothelia  of  blood- 

,          ,  -.-IT  »  ii        i  i  ••       UNSUCCESSFUL  PHAGO- 

vessels,  alveolar  epithelium  01  the  lungs,  and  certain  CYTOSIS. 
cells  of  bone,  marrow,  lymphatic  glands,  the  spleen,  etc.  The  process 
is  accomplished  by  amoeboid  action,  the  cell  folding  or  closing  the 
microbe  within  its  substance,  and  afterward  destroying  it  by  some 
process,  probably  digestive  in  character.  Cells  which  are  supposed 
to  accomplish  this  action  are  termed  phagocytes.  Sometimes  the 
microbes  multiply  in  the  cells  in  such  numbers  that  the  phagocytes 
are  destroyed  instead,  and  fatal  results,  general  or  local,  follow. 
Against  the  testimony  of  Metschnikoff,  who  asserts  that  he  has  wit- 
nessed the  operation  of  phagocytosis,  we  have  the  statements  of 
other  eminent  pathologists  that  cells  do  not  possess  the  power  of 
destroving  microbes  which  inhabit  their  substance.  As  there  seem 
to  be  very  positive  statements  upon  both  sides  of  this  proposition, 
it  is  evident  that  the  question  requires  future  time  for  its  complete 
solution. 

Chronic  inflammation  is  attended  by  much  less  vascular  excitement 
than  the  acute  form.     Consequently,  migration  of  leucocytes  is  lim- 


26  INTRODUCTION. 

ited,  if  occurring  at  all,  and  the  inflammatory  transudation  is  derived 
chiefly  from  the  fixed  tissue-cells,  young  cells  here  playing  an  active 
role.  New  tissue  is  developed,  which,  if  it  be  not  removed  during 
the  reparative  stage,  constitutes  a  permanent  hyperplasia.  Hyper- 
plasia  of  connective  tissue  figures  prominently  in  the  morbid  auat- 
o.ny  of  interstitial  inflammation  of  the  liver,  lungs,  brain  and  spinal 
c  >rd,  choking  out  functional  cellular  structures  iu  these  organs,  and 
strangulating,  by  slow  process  of  contraction,  the  circulation  of  blood, 
upon  which  their  functional  activity  depends. 

Another  result  of  chronic  inflammation  is  the  development  of 
granulation-tissue,  which  is  composed  largely  of  embryonal  cells,  cor- 
responding to  the  type  of  tissue  in  which  or  from  which  they  grow, 
modified  by  disease-influences,  such  as  the  presence  of  microbes. 
The  gummata  of  syphilis  may  be  cited  as  an  illustration  of  this  class 
of  growths. 

TERMINATIONS  OF  INFLAMMATION. 

The  inflammatory  process  may  be  arrested  at  almost  any  step  in 
its  course,  and  the  termination  of  the  morbid  action  be  consequently 
modified  by  the  stage  of  arrest.  If  the  irritation  is  not  severe  and 
the  morbid  action  ceases  before  there  has  been  destruction  of  tissue 
and  purulency,  the  exudation  is  absorbed  and  the  tissues  are  left  in 
a  normal  condition,  resolution  having  taken  place.  Long-continued 
inflammation,  however,  results  in  the  death  of  the  tissue-cells  near 
the  point  of  most  concentrated  excitement,  and  as  there  is  liable  to 
be  a  lodgment  of  many  leucocytes  here,  we  may  have  necrosis  of  tis- 
sue with  purulent  degeneration  of  the  surrounding  parts,  constituting 
what  is  termed  suppuration. 

Pus  consists  of  two  parts :  (1 )  Corpuscular  elements  derived  from 
leucocytes  and  embryonal  tissue-cells,  which  have  undergone  de- 
structive changes;  and  (2)  pus-serum,  a  fluid  derived  from  the  in- 
flammatory trausudation.  The  formation  of  pus  depends,  in  infec- 
tious inflammation,  upon  the  direct  action  of  microorganisms  upon 
the  leucocytes  and  embryonal  cells  (unsuccessful  phagocytosis),  or 
upon  the  destructive  action  of  the  toxines  generated  by  them  upon 
these  bodies.  Pus,  however,  may  arise  from  other  causes,  as  certain 
chemicals  injected  into  the  tissues  will  cause  similar  changes.  Severe 
inflammatory  action  from  any  cause  may  prove  destructive  to  the 
elements  which  afterward  degenerate  into  pus. 

When  purulent  destruction  occurs  upon  an  open  surface,  and  is 
gradual  (and  attended  by  molecular  disintegration),  the  pus  escapes 
freely,  and  constitutes  idceration.  When  a  considerable  portion  of 
tissue  is  simultaneously  involved  in  necrotic  change,  it  is  removed 
in  a  mass,  and  is  termed  a  slough.  If  pus  accumulates  in  the  tissues, 
an  absciss  is  the  result.  The  disposal  of  the  pus  in  such  a  case  will 


INFLAMMATION.  27 

depend  upon  circumstances.  If  it  be  small  in  amount,  and  the  sur- 
rounding tissues  are  in  an  excellent  condition  of  health,  the  rather 
uncommon  result  of  absorption  may  occur,  the  corpuscular  elements 
being  first  liquefied.  However,  the  pus  is  commonly  evacuated  by  a 
burrowing  process,  the  surface  being  reached  through  the  least- 
resisting  tissues,  in  a  direction  suggested  by  the  force  of  gravity, 
in  many  instances. 

Occasionally,  pus  may  be  inspissated,  and  retained  in  the  tissues, 
the  process  being  technically  termed  caseation.  It  suggests  degener- 
ative changes  later  on. 

In  chronic  inflammation,  the  inflammatory  action  is  not  severe 
enough  to  destroy  the  tissue-cells,  and  they  are  stimulated  sufficiently 
to  undergo  multiplication  and  rapid  reproduction  (proliferation). 
Connective  tissue  is  especially  prone  to  active  proliferation  of  cells 
when  chronically  inflamed,  and  when  the  stroma  of  organs  like  the 
liver,  kidneys,  lungs,  etc.,  becomes  thus  involved,  the  inherent  con- 
traction which  follows  the  development  of  this  tissue  in  the  interior 
of  an  organ  gives  rise  to  obliteration  of  circulating  vessels  and  paren- 
chyma-cells, until  the  functions  of  the  part  may  be  completely 
destroyed,  the  organ  becoming  hardened,  and  presenting  the  condi- 
tion known  as  cirrhosis. 

The  destruction  of  tissue  following  necrosis  of  cellular  elements 
is  usually  replaced  by  proliferation  of  connective-tissue  cells,  which 
organize  and  fill  up  the  vacancy.  When  this  occurs  upon  the  surface,  a 
kind  of  epithelial  covering — not  exactly  like  the  original  one — covers 
in  the  new  growth.  New  growths  of  connective  tissue  also  fill  up 
pus-cavities  in  the  deeper  structures,  more  or  less  contraction  mark- 
ing each  point  afterward  The  new  growth  is  termed  a  cicatrix. 

Symptoms. — In  mild  cases  of  acute  inflammation,  the  local  man- 
ifestations are  the  only  observable  symptoms ;  and  these  vary  much, 
according  to  the  part  or  tissue  involved.  However,  in  all  acute 
inflammations  there  is  a  group  of  symptoms,  more  or  less  well- 
marked,  not  easily  overlooked.  These  are,  increased  local  heat,  red- 
ness, swelling,  pain,  and  impairment  of  function.  In  chronic  inflam- 
mation, the  disease  may  be  so  insidious  in  its  progress  that  vital 
organs  are  fatally  impaired  before  the  patient  is  conscious  that  he  is 
seriously  ill. 

In  acute  infectious  inflammation,  as  well  as  in  other  cases  involv- 
ing important  organs  extensively,  constitutional  disturbances,  which  are 
usually  well  marked,  accompany  the  local  symptoms,  and  the  local 
irritation  is  proportionally  severe.  The  onset  is  liable  to  be  marked 
by  chilliness,  if  not  by  an  actual  rigor.  Reaction  is  attended 
by  pronounced  febrile  symptoms,  such  as  elevation  of  the  tempera- 


28  INTRODUCTION. 

ture  of  the  general  circulation,  arrest  of  secretion  and  excretion  to  a 
certain  extent,  restlessness,  etc.  If  the  inflammatory  action  con- 
tinues for  several  days  with  unmitigated  severity,  hectic  fever  and 
colliquative  sweats  begin  to  appear.  A  chill,  occurring  after  inflam- 
matory action  has  been  established  for  several  days,  suggests  com- 
mencing suppuration  in  some  important  organ. 

One  of  the  first  prominent  symptoms  of  inflammation  is  increased 
local  redness,  this  being  due  to  the  active  hypersemia  which  occurs 
in  the  beginning.  Though  this  may  not  always  be  a  prominent  fea- 
ture, close  inspection  of  vascular  tissue  will  usually  detect  engorge- 
ment at  the  point  where  the  active  disturbance  is  progressing. 
Later,  after  the  active  stage  has  passed  and  the  vessels  become 
packed  with  corpuscles  which  move  through  the  vessels  but  slowly 
if  at  all,  the  bright  redness  of  the  active  stage  gives  way  to  a  darker 
red,  or  purple  hue. 

The  increased  amount  of  blood  in  the  part  gives  rise  to  dilatation 
of  blood-vessels,  general  swelling,  and  augmented  local  heat.  The 
elevation  of  local  temperature  is  readily  demonstrated  when  a  ther- 
mometer is  applied  to  the  surface  of  the  affected  part  and  its  tem- 
perature compared  with  that  of  other  portions  of  the  surface  not 
affected.  The  local  elevation  has  no  direct  reference  to  the  general 
elevation,  which  is  due  to  systemic  infection  and  its  influence  upon 
the  heat  centers.  The  local  elevation  of  temperature  sustains  a 
direct  relation  to  the  amount  of  blood  in  the  part. 

The  inflammatory  exudation  is  an  element  to  be  added  to  the 
local  hypersBmia  in  the  causation  of  the  tumefaction.  Fluids  are 
poured  out  from  the  damaged  vessels  to  distend  the  para-vascular 
tissues,  and  to  these  are  to  be  added  the  transudation  from  the 
fixed  tissue-cells,  as  well  as  the  corpuscular  elements  which  have 
escaped  from  the  blood-vessels.  Inflammatory  transudation  differs 
from  the  transudation  of  simple  oedema,  in  that  the  inflammatory 
transudation  contains  albuminous  elements,  while  these  are  absent 
from  dropsical  effusion. 

Pain  is  a  result  of  the  swelling,  which  causes  pressure  upon  the 
extremities  of  sensory  nerves.  However,  the  amount  of  pain  is  not 
proportionate  to  the  amount  of  swelling,  the  resistance  of  the  struc- 
ture involved  determining  the  amount  of  pressure  and  consequent 
compression  of  nervous  structure.  Loose  tissues  may  be  swollen 
remarkably  and  yet  not  be  very  painful,  while  inflammation  of  firmer 
parts  may  give  rise  to  excruciating  pain,  and  not  present  much  of  a 
swollen  appearance.  The  resistance  offered  to  the  inflammatory  exu- 
dation determines  the  amount  of  pain,  to  a  great  extent.  The  pain 
of  acute  inflammation  is  usually  throbbing  in  character,  this  being 
due  to  increased  pulsation  of  all  the  minute  arteries,  as  well  as  to 


INFLAMMATION.  29 

the  exalted  sensibility  of  the  nerves  of  the  affected  part.  Accom- 
panying the  throbbing  sensation  may  be  paroxysms  of  darting  or 
burning  pain. 

All  the  symptoms  of  inflammation  may  be  fully  developed  within 
twenty-four  hours  after  commencement,  though  usually  a  longer 
time  is  consumed  in  its  full  development,  and  the  symptoms  may  be 
progressive  for  several  days,  in  severe  infectious  cases.  The  extent 
to  which  a  part  may  become  involved  will  depend  upon  the  viru- 
lence of  the  existing  cause,  partly,  and  partly  upon  the  receptivity 
of  the  tissues  to  its  action. 

Tenderness  on  pressure  is  a  very  important  symptom  of  inflam- 
matory action.  Sensitiveness  is  a  condition  which  is  almost  always 
present,  even  if  the  part  be  painless  when  undisturbed.  In  some 
cases  the  pain  is  reflex,  the  irritation  being  manifested  in  a  part  dis- 
tant from  the  real  point  of  morbid  action.  In  morbus  coxarius,  for 
example,  the  inflammation  is  in  the  hip  joint,  while  the  pain  is  in  the 
knee.  Pressure  upon  the  trochanter  in  such  a  direction  as  to  crowd 
the  head  of  the  femur  into  the  acetabulum  will  elicit  tenderness, 
while  no  ordinary  amount  of  pressure  about  the  knee  will  cause  dis- 
comfort. In  some  cases  of  proctitis,  the  pain  will  be  in  the  hip, 
along  the  sciatic  nerve  or  in  some  other  remote  part,  while  pressure 
about  these  regions  will  fail  to  elicit  tenderness,  and  the  actual  seat 
of  the  disease  is  only  demonstrable  after  careful  examination  of  the 
rectum.  The  pain  of  eudometritis  may  be  persistently  manifested 
in  the  ovarian  region,  but  tenderness  will  not  be  discovered  until 
the  uterine  cervix  is  disturbed. 

In  some  cases,  impairment  or  perversion  of  function  may  be  the 
only  prominent  symptom  of  inflammatory  action.  The  almost  com- 
plete arrest  of  the  urinary  discharge  in  acute  Bright's  disease  may 
be  the  first  noticeable  symptom.  The  gravity  of  a  case  may  not 
depend  so  much  upon  the  comparative  amount  of  tissue  destroyed, 
as  upon  the  character  of  the  function  impaired.  For  example,  the 
tissue-destruction  involved  in  a  fatal  case  of  pneumonia  might  not 
be  of  such  serious  consequence  were  it  not  for  the  arrest  of  the 
important  oxygenating  functions  of  the  parts  involved.  And  arrest 
of  this  function  will  give  rise  to  the  leading  symptoms  of  the  case, 
such,  for  instance,  as  hurried  respiration,  dyspnoea,  cyanosis,  cough, 
expectoration,  etc. 

It  thus  becomes  apparent  that  any  attempt  to  describe  the  diver- 
sified symptoms  of  inflammation  within  the  limited  scope  of  a  siugle 
article,  must  be  rambling  and  unsatisfactory.  Indeed,  much  of  the 
space  in  the  following  pages  will  be  occupied  in  the  consideration  of 
the  symptoms  of  various  inflammatory  conditions. 


30  INTRODUCTION. 

Treatment. — The  diversified  conditions  liable  to  be  met  in  a 
variety  of  cases  of  inflammation,  render  it  inexpedient  to  attempt  to 
cover  the  ground  occupied  by  the  proper  treatment  of  individual 
forms  in  this  place.  This  will  be  the  task  to  be  fulfilled  in  the  pages 
which  follow.  However,  there  are  certain  well-established  principles 
to  be  observed  in  all  instances,  and  a  consideration  of  these  will 
assist  the  practitioner  very  much  in  individualizing  his  cases. 

There  is  much  to  be  considered  in  a  proper  regiminal  treatment, 
in  discussing  the  general  management  of  inflammation.  Provisions 
against  irritation  of  an  already  inflamed  part  are  as  important  as  cur- 
ative means,  and  these  often  amount  to  as  much  if  not  more  than 
medicinal  treatment.  Kest  to  an  inflamed  part  means  much  when  its 
activity  augments  inflammatory  action,  as  is  often  the  case. 

Rest  being  important  in  treating  inflammation  of  any  part,  the 
questions  arise,  What  does  it  constitute,  and  how  shall  it  be  attained? 
These  the  physician  of  practical  turn  will  nearly  always  be  able  to 
solve  by  the  application  of  common-sense  principles  to  individual 
cases.  It  is  axiomatic  that  neither  excessive  functional  activity 
nor  abnormal  irritation  of  an  organ  or  part  should  be  allowed  to 
continue  longer  than  salutary  measures  will  suffice  to  repress  it. 

To  illustrate,  imagine  a  case  of  recto-colitis,  in  which  the  evacua- 
tions are  frequent,  and  attended  by  severe  tormina  and  tenesmus. 
Suppose  now  that  the  patient  be  allowed  to  rise  and  sit  upon  a  stool 
at  every  period  of  evacuation,  thereby  adding  to  the  irritation  by 
change  of  position  and  by  voluntary  straining.  In  such  a  case — 
which  is  no  uncommon  illustration  of  the  management  pursued  by 
many — the  therapeutist  may  find  his  best  prescriptions  at  fault 
many  times,  and  will  occasionally  find  his  patient  growing  worse 
instead  of  better,  until  he  has  enjoined  quiet  in  the  recumbent  pos- 
ture with  the  use  of  a  bed-pan  during  evacuation,  and  instructed  the 
patient  to  exercise  the  will-power  to  postpone  the  attempts  at  evac- 
uation as  long  as  possible,  in  order  that  straining  and  other  causes 
of  hypersemia  thus  entailed  may  occur  only  at  prolonged  intervals. 
Prompt  response  to  the  properly  selected  remedies  will  then  follow, 
and  the  benefit  of  rest  to  the  affected  part  will  become  so  prominent 
that  no  one  can  doubt  its  presence.  Take,  again,  a  case  of  irritation  of 
the  respiratory  mucous  membrane  arising  from  measles.  Suppose, 
now,  the  patient  be  allowed  to  remain  during  the  course  of  the  dis- 
ease in  an  apartment  where  the  temperature  is  below  the  freezing 
point,  the  cold  air  acting  as  a  local  excitant  to  the  irritated  surface. 
The  best  remedies  we  may  select  here  cannot  equal,  in  beneficial 
results,  the  adoption  of  means  to  bring  the  temperature  up  to  65° 
or  70°  F.  and  maintain  it  there,  during  the  continuance  of  the  bron- 


INFLAMMATION.  31 

chial  irritation.  Indeed,  neglect  of  this  measure  may  result  fatally 
in  cases  which  would  terminate  favorably  under  proper  surround- 
ings without  any  medication  at  all,  pulmonary  inflammation  being 
excited  by  the  irritation  set  up  from  the  excessive  cough,  arising 
from  exposure  of  the  pulmonary  membrane  to  the  chilly  atmosphere. 
Suppose  a  case  of  chronic  laryngitis,  due  to  the  titillating  influ- 
ence of  an  elongated  uvula.  Could  it  be  reasonably  expected  that 
medicine  would  cure  the  i.isease  while  the  cause  of  irritation  was 
remaining? — Certainly  not.  And  the  physician  who  possessed  such 
an  exalted  opinion  of  remedies  as  to  expect  it,  would  be  blind  to 
the  true  philosophy  of  therapeutics. 

The  rest  which  irritated  and  inflamed  organs  receive  from  opi- 
ates is  seductive,  and  usually  of  little  permanent  good,  while  the 
effect  of  the  drug  is  often  harmful  to  the  general  condition  of  the 
patient,  impairing  his  recuperative  energies.  However,  this  favorite 
method,  long  perpetuated  by  the  dominant  school,  is  not  to  be 
abandoned  completely,  though  its  omission  should  be  the  rule 
rather  than  the  exception. 

Position  may  exert  an  important  influence  upon  the  results  of 
inflammatory  action,  when  this  operates  upon  the  circulation  of  the 
affected  part.  Hypostatic  pressure  is  influenced  by  gravity,  even 
within  the  body;  and  flexure  of  certain  parts  may  compress  impor- 
tant blood-vessels  to  impede  the  circulation,  when  the  force  of  gravity 
is  not  at  fault.  Destructive  and  fatal  pneumonia  may  arise  during 
typhoid  fever,  from  allowing  the  patient  to  remain  constantly  upon 
the  back  for  weeks  at  a  time,  the  fatal  effects  of  hypostatic  pressure 
upon  debilitated  tissues  being  here  demonstrated.  Chronic  metritis 
may  be  due  to  flexion  of  the  uterine  cervix  impeding  the  circulation 
of  blood  through  the  uterine  vessels. 

Undoubtedly,  inflammatory  conditions  of  the  intestinal  walls  are 
often  aggravatad  by  the  local  effect  of  improper  food.  Fatal  cases  of 
typhoid  fever  may  owe  their  unfortunate  termination  to  such  influ- 
ences; and  dysentery,  which,  under  proper  management,  would  ter- 
minate favorably  in  brief  time,  may  be  prolonged  until  permanent 
chronic  disease  is  the  result,  because  proper  attention  has  not  been 
given  to  the  fact  that  a  local  hyperaemia  exists  in  the  intestinal 
mucous  membrane,  which  renders  careless  and  indiscriminate  feeding 
highly  improper  and  detrimental. 

These  few  illustrations  will  suggest  the  proper  course  to  the  dis- 
criminating practitioner.  Give  therapeutics  their  proper  place,  and 
do  not  expect  them  to  accomplish  impossibilities. 

It  is  evident,  then,  that  many  more  details  are  to  be  considered  in 
the  management  of  inflammation  generally,  than  those  which  concern 


32  INTRODUCTION. 

the  administration  of  remedies;  for,  though  these  are  highly  impor- 
tant, neglect  of  a  proper  regimen  may  neutralize  the  best-directed 
therapeutic  efforts,  and  subject  the  most  reliable  remedies  to 
condemnation. 

In  the  therapeutic  management  of  inflammation,  we  must  be 
guided  by  the  stage  which  has  been  reached  in  pathological  develop- 
ment, the  relief  of  irritation  and  conservation  of  the  vitality  of  the 
part  affected  being  the  principal  objects  sought.  "We  will  leave  the 
destruction  of  pathological  microbes  concerned  to  the  bacterio- 
logical enthusiast  and  neophyte,  and  concern  ourselves,  in  this  direc- 
tion, with  neutralizing  the  ptomaines  generated,  and  reenforcing 
physiological  processes,  so  far  as  possible. 

Let  us  first  consider  the  treatment  of  active  hypercemia;  for,  in 
the  proportion  that  this  can  be  controlled,  in  a  corresponding  ratio 
will  the  integrity  of  the  tissues  involved  be  preserved.  Two  classes 
of  remedies  are  to  be  considered  here,  namely,  (1)  general  vas- 
cular sedatives,  and  (2)  local  vascular  sedatives. 

The  general  vascular  sedatives  have  already  been  considered, 
under  treatment  of  fevers.  They  include  the  special-sedative  class 
of  Scudder,  and  the  antiseptic  sedatives.  These  are  to  be  employed 
to  control  the  symptomatic  fever,  usually,  though  they  should  not 
be  considered  mere  appendices  of  this  character,  as  inflammations 
in  which  constitutional  symptoms  are  not  prominent  are  manifestly 
modified  by  them.  Indeed,  the  hypersemic  conditions  of  inflammation 
may  be  successfully  treated  without  other  means,  except  properly 
selected  local  applications.  As  the  appropriate  method  of  employ- 
ing these  remedies,  as  well  as  their  adaptation,  has  already  been  dis- 
cussed, the  reader  is  referred  to  preceding  pages  (10,  11,  12,  13, 
14),  and  to  Dynamical  Therapeutics,  for  further  suggestions. 

However,  we  can  improve  upon  this  treatment  by  adding  a  class 
of  remedies — local  vascular  sedatives — which  sedate  special 
localized  vascular  areas.  For  example,  while  we  may  treat  pneumonia 
with  tolerable  satisfaction  by  the  use  of  aconite,  gelsemium,  jab- 
orandi,  and  other  general  vascular  sedatives,  we  will  derive  better 
satisfaction  by  combining  with  the  properly  selected "  general  seda- 
tive, a  remedy  from  the  group  which  sedates  the  vascular  area  sup- 
plied with  blood  by  the  bronchial  arteries;  such,  for  example,  as 
asclepias,  bryonia,  ipecac,  lobelia  (?),  etc.  So  with  acute  pharyngi- 
tis. The  general  sedatives  may  control  the  local  vascular  excite- 
ment, and  the  results  be  very  satisfactory  to  those  accustomed  to 
older  and  less  direct  methods;  but  more  rapid  and  satisfactory 
results  follow  when  phytolacca,  cistus  canadensis,  or  some  other 
agent  which  specifically  influences  the  vascular  area  supplying  the 


INFLAMMATION.  33 

pharynx  is  added  for  its  sedative  effect.  The  local  sedative  usu- 
ally acts  with  greater  therapeutic  power  upon  the  special  part 
than  the  general  sedative,  but  the  combination  acts  best  to  cover 
both  general  and  local  disturbances  of  active  hypersemia.  If  we 
make  a  careful  study  of  dynamical  therapeutics,  we  will  find  that 
many  different  parts  and  organs  possess  their  specific  vascular  seda- 
tives, which  exert  an  important  influence  in  controlling  hypersemic 
conditions. 

By  the  use  of  such  agents  we  may  be  enabled  to  so  control  the 
active  hyperaamia  of  the  affected  part  as  to  quiet  the  inflammatory 
action  before  the  later  stage,  such  as  migration  of  leucocytes,  inflam- 
matory engorgement,  stasis,  alteration  of  fixed  tissue-cells,  etc.,  has 
made  much  progress.  Consequently,  there  is  little  exudation  to  be 
absorbed,  and  the  blood-vessels  and  fixed  tissue-cells  are  saved  from 
damage,  while  necrotic  processes  are  averted,  recovery  then  being 
rapid  and  complete.  It  matters  little  how  severe  an  inflammation  may 
be,  faithful  adherence  to  such  principles  is  sure  to  provide  against 
the  worst  results,  which  might  ensue  without  their  observance. 

When  the  para-vascular  tissues  become  involved,  the  disease  has 
progressed  beyond  the  reach  of  vascular  therapeutics.  However,  as 
para-vascular  disturbances  may  go  on  simultaneously  with  hypersemia, 
it  is  not  in  order  to  abandon  our  sedatives  upon  the  adoption  of  a 
new  line  of  treatment.  These  should  be  continued,  and  alternated 
with  additional  measures,  as  long  as  active  hyperaemia  persists. 

The  period  of  commencing  inflammatory  exudation  announces 
the  time  for  a  new  step  in  the  treatment  of  all  severe  cases  of  inflam- 
mation. Wherever  the  formation  of  pus  would  be  disastrous,  as 
in  inflammation  of  any  internal  organ, — where  its  exit  might  be 
attended  by  serious  consequences, — it  is  highly  important  that  this 
purulent  degeneration  be  forestalled  and  prevented,  if  possible,  as 
it  often  is.  In  many  cases  of  pelvic  cellulitis,  typhlitis,  hepatitis, 
pneumonia,  etc.,  where  purulent  accumulation  might  otherwise  occur, 
potassium  chloride,  3x  trituration,  properly  employed,  will  assist 
the  normal  processes  to  remove  and  dispose  of  inflammatory  exuda- 
tion so  safely  as  to  leave  no  bad  results  behind,  and  convert  por- 
tentous cases  into  that  favorable  form  where  resolution  disposes  of 
serious  sequlae.  It  is  remarkable  how  soon  pain,  hectic  fever,  and 
tenderness  will  vanish  before  this  remedy,  in  a  large  majority  of  cases. 
True,  weeks  may  be  required  to  bring  about  the  desired  results  in 
some  cases,  and  the  remedy  may  fail,  as  all  others  will ;  but  it  is  one 
of  the  most  precious  boons  of  modern  therapeutics,  after  all.  Add 
five  grains  of  the  3x  trituration  to  half  a  glass  of  water,  and  give  a 
teaspoon ful  every  hour. 


34  INTRODUCTION. 

A  step  further,  and  we  find  that  purulency  cannot  be  controlled. 
We  now  need  a  remedy  which  will  hasten  the  change  rapidly,  that  as 
small  a  portion  of  tissue  as  possible  may  be  sacrificed ;  and  we  will 
resort  to  calcium  sulphide,  for  this  purpose.  When  there  is  a  tend- 
ency to  persistency  of  suppurative  action,  this  remedy  will  often 
assist  promptly  in  bringing  the  degenerative  change  to  an  end,  as, 
for  instance,  where  there  has  been  purulent  pneumonia,  and  the  pus 
cavity  continues  to  suppurate  after  evacuation,  preventing  the 
maturity  of  embryonal^  tissue-cells,  and  the  repair  of  the  part. 

Then  we  have  more  extreme  cases,  where  a  sloughing  tendency 
is  announced  by  purple  tissues,  with  darkened  center,  or  perhaps 
actual  necrosis  of  the  focus  of  inflammatory  action,  with  manifest 
progression  of  the  necrotic  change,  where  none  of  the  remedies  already 
named  will  be  of  much  if  any  account.  It  is  here  that  we  will  expect 
to  derive  the  wonderful  influence  of  echinacea,  employing  it  both 
internally  and  locally,  saturating  the  system  with  it,  and  stimulating 
local  areas  by  its  direct  action.  Nothing  like  this  remedy  was  ever 
known  in  medicine  before  its  time,  and  the  physician  who  neglects  to 
avail  himself  of  it  is  sacrificing  the  vital  interests  of  his  patient 
where  marked  uecrotic  tendencies  are  developing.  From  ten  to 
Wenty  drops  of  a  saturated  tincture  of  the  fresh  plant  may  be  given 
every  hour,  and  a  dilution  of  one  part  of  the  same  to  three  or  four 
of  water  should  be  applied  locally  at  frequent  intervals.  Another 
remedy  of  this  character  is  baptisia,  a  traditional  agent  for  such  con- 
ditions, and  one  which  deserves  much  praise,  though  it  does  not 
compare  with  echinacea  in  efficacy. 

Then  we  have  a  class  of  inflammations  where  the  skin  and  its 
reflections  are  involved  in  erythematous  or  erysipelatous  irritation, 
the  condition  being  marked  by  tendency  to  rapid  spreading,  and 
severe  burning  pain.  Here  we  get  the  best  effects  from  echinacea  inter- 
nally, though  it  may  be  assisted  by  aconite,  jaborandi,  or  some  other 
appropriate  special  sedative,  and  its  local  influence,  which  is  most 
effective,  may  be  assisted  by  applications  of  plumbi  acetatis,  citric  acid, 
etc.,  in  solution.  Where  such  conditions  become  chronic,  the  grand 
constitutional  influence  of  berberis  aquifolium,  should  not  be  forgotten. 

The  symptomatic  fever  which  attends  inflammation  will  call  for  the 
medication  already  directed  under  the  general  treatment  of  fevers 
The  sedatives,  both  arterial  and  antiseptic,  should  be  properly  adapted 
when  called  for;  and  the  element  periodicity  should  be  recognized  and 
properly  met,  if  success  is  to  be  expected  to  follow  treatment 

The  local  treatment  of  inflammation  has  undergone  quite  a  rev- 
olution since  the  days  of  bacteriology.  Hot  poultices,  once  the 
favorite  resort  of  the  practitioner,  have  been  relegated  to  the  past,  their 


INFLAMMATION.  35 

use  being  opposed  to  antiseptic  precautions,  it  being  believed  that  they 
furnish  a  nidus  for  the  development  of  pathogenic  germs.  Cold, 
applied  over  the  affected  surface,  is  less  conducive  to  suppuration, 
and  water  may  be  used  to  saturate  appropriate  packs  for  this  pur- 
pose. The  temperature  of  the  water  employed  should  depend  upon 
the  patient,  one  of  delicate  nervous  organization  not  being  well 
adapted  to  resist  the  shock  of  very  cold  applications.  Tepid  water 
would  suit  such  individuals  best,  and  impart  all  the  beneficial  influ- 
ence to  be  derived.  In  pneumonia,  especially  in  children,  cold-  or 
tepid-water  packs  should  rank  among  the  best  means  of  treatment 
during  the  stage  of  active  hyperaemia;  and  such  remark  applies  to 
acute  inflammatory  action  in  almost  any  other  organ.  Where  super- 
ficial surfaces  are  involved,  some  appropriate  medicine  may  be  added 
to  the  water,  which  will  serve  both  as  a  therapeutic  agent  and  vehi- 
cle to  carry  the  medicine.  For  instance,  superficial  inflammation 
of  the  skin  may  require  the  local  influence  of  diluted  carbolic  acid, 
echinacea,  citric  acid,  or  some  other  cooling,  soothiug,  or  cleansing 
agent. 

The  diet  of  inflammation  should  be  nutritious,  but  not  stimulating. 
The  old  idea  that  inflammation  should  be  starved  out,  was  a  much 
mistaken  one,  and  has  long  since  given  way  to  more  sensible  views. 
The  waste  of  tissue  and  expenditure  of  heat  involved  calls  for  nour- 
ishment to  make  good  the  loss,  and  demands  that  the  patient  be 
properly  fed. 

In  active  inflammatory  states  of  severe  character,  a  diet  of  milk 
may  be  all  that  is  desirable,  this  being  diluted  one-half  with  w^ter 
or  Vichy.  A  better  diet  here  will  be  found  to  consist  of  malted 
milk,  though  the  patient  soon  tires  of  this  form  of  food.  From  311 
to  seven  ounces  of  milk  may  be  administered  every  two  hours. 
Where  the  alimentary  canal  is  involved,  the  diet  must  be  selected 
with  reference  to  existing  conditions,  care  being  observed  to  avoid 
everything  liable,  from  its  indigestibility  or  mechanical  influence, 
to  irritate  the  sensitive  mucous  membrane.  Malted  milk  or  beef- 
peptonoids  will  here  be  found  excellent,  preference  being  given  to 
malted  milk.  Gruels,  prepared  from  arrowroot  or  oatmeal,  some- 
times break  the  monotony  of  a  continuous  milk  diet,  and  serve  an 
excellent  purpose  as  nutritives.  Bicewater  is  very  nourishing,  and 
serves  at  the  same  time  as  a  cooling  drink  in  inflammatory  diseases. 
The  cream  from  cream-codfish  is  excellent,  and  unobjectionable  dur- 
ing the  later  stages,  after  inflammation  has  somewhat  subsided.  At 
this  time  the  yolks  of  eggs  which  have  been  boiled  an  hour,  will  be 
found  nourishing  and  unirritating.  Eggnog — though  alcoholic  stim- 
ulants are  rarely  demanded — may  now  be  administered  sparingly. 


36  INTRODUCTION. 

When  acids  are  indicated  by  the  tongue  and  craved  by  the  patient, 
they  are  excellent  in  the  form  of  acidulated  driuks,  such  as  lemonade, 
acid  phosphate,  etc.  Later  on,  a  light  diet  of  toast,  poached  eggs  on 
toast,  custard,  rice,  etc.,  may  be  indulged  in.  Tea  and  coffee  should 
be  used  sparingly,  if  at  all. 

HYPEKTEOPHT. 

HYPERTROPHY  is  enlargement  of  an  organ  or  part  from  increase 
in  the  size  or  number  of  its  numerical  elements.  Simple  increase 
in  bulk,  however,  may  occur  without  constituting  hypertrophy,  as 
proliferation  of  cells  of  new  growth  or  of  connective  tissue  may 
occur  to  increase  bulk,  without  adding  to  the  function-elements. 
Various  degenerations  may  also  increase  the  size  of  a  part,  which 
could  not  then  be  considered  as  hypertrophiecl. 

In  order  that  a  muscle  may  be  hypertroplded,  there  must  be  an 
increase  in  the  size  or  in  the  number  of  the  muscle-cells.  In  hyper- 
trophy of  the  thyroid  gland,  there  must  be  an  increase  in  the  number 
or  size  of  the  normal  cellular  elements  of  the  part;  therefore,  some 
cases  of  goitre  are  true  hypertrophies,  while  others  are  due  to  degen- 
eration or  hyperplasia.  In  true  hypertrophy  the  enlargement  must 
be  due  to  increase  in  the  normal  cells  of  the  part. 

Normal  hypertrophy  frequently  occurs,  as,  for  example,  when 
there  is  an  increase  in  the  elements  of  the  uterine  structure  and  of 
the  mammary  glands  during  the  developments  of  gestation.  The 
hypertrophy  of  the  muscles  of  the  calf  in  the  ballet-dancer,  of  those 
of  the  forearm  in  the  blacksmith,  etc.,  is  of  a  similar  nature,  though 
in  every  instance  it  must  be  considered  as  compensatory — a  develop- 
ment in  keeping  with  the  requirements  of  the  case.  An  example  of 
compensatory  hypertrophy  is  afforded  by  the  hypertrophy  of  the 
heart  when  obstruction  of  the  orifices  demands  the  exhibition  of 
greater  power  to  propel  the  blood  through  them  in  a  given  space 
of  time. 

Irritation,  which  invites  undue  afflux  of  blood  to  a  part,  may  result 
in  hypertrophy.  The  enlargement  of  the  cheeks  and  nose  in  acne 
rosacea  probably  depends  upon  this  principle.  In  inflammation,  the 
surrounding  area  is  stimulated  to  greater  than  normal  activity,  and 
hyper-growth  of  normal  tissue  may  result,  as  enlargement  of  bone 
in  periostitis.  The  process  by  which  hypertrophy  develops  from  the 
normal  elements  of  a  part  is  one  of  cell  growth,  of  which  there 
are  two  kinds,  namely,  direct  and  indirect  Indirect  cell  develop- 
ment is  technically  termed  karyokinesis.  Recent  advances  in  biol- 
ogy have  improved  our  knowledge  of  the  minute  structure  and 
developmental  history  of  cell  growth  in  this  particular. 


ATROPHY. 


37 


Modern  knowledge  of  cell  structure  differs  materially  from  the 
conception  entertained  by  older  writers,  such  as  Schwaun,  Remak, 
and  Virchow,  who  held  that  a  structureless  mass  of  protoplasm  con- 
taining a  homogeneous  nucleus  was  the  essential  feature.  Some  writ- 
ers even  contended  that  a  nucleus  was  not  necessaary,  a  simple  mass 
of  protoplasm  representing,  in  certain  instances,  an  individual  cell. 
For  the  purpose  of  karyokiuesis,  however,  a  much  more  complicated 
structure  is  essential,  and  more  complete  researches  into  the  minute 
structure  of  the  histological  formation  of  cells  have  demonstrated 
that  a  nucleus  with  internal  organization  is  an  important  essential 
of  this  process. 


SUCCESSIVE  STEPS  IN  KAHYOKINESIB. 

The  nucleus  contains  a  reticulum  of  minute  fibers,  the  meshes  of 
which  are  filled  with  a  homogeneous  substance.  From  the  fact  that 
the  fibers  may  be  stained  with  certain  coloring  matters  they  have 
been  termed  chromatin  threads,  while  the  homogeneous  substance  it 
contains,  resisting  colors,  is  termed  achromatic.  The  cell  contents 
outside  the  nucleus  also  contain  fibers,  irregularly  distributed 
through  its  substance.  When  the  cell  is  in  a  quiescent  condition 
the  chromatin  threads  are  very  slight;  but  when  karyokinesis 
begins,  they  become  swollen,  and  converted  into  a  skein  of  convo- 
luted fibers.  This  afterward  assumes  the  shape  of  a  star,  the 
wall  of  the  nucleus  meanwhile  disappeariDg.  Then  follows  the 
equatorial  stage,  in  which  the  chromatin  fibers  divide  into  two 
groups  and  cluster  about  the  poles  of  the  nucleus,  a  clear  space 
bring  left  along  the  equatorial  line.  Then  the  cell  wall  contracts 
in  this  region  and  a  separation  of  the  two  parts  follows,  the  chrom- 
atin threads  in  each  cell  subsiding  into  the  former  condition  of 
quiescence,  and  becoming  surrounded  by  a  limiting  membrane. 

ATROPHY. 

ATROPHY  is  a  diminution  in  the  size  of  an  organ  or  part,  due  to 
loss  of  substance  in  its  histological  elements,  or  decrease  in  the 
number  of  such  parts. 

Where  the  decrease  is  only  that  of  size  of  elemental  parts,  the 
condition  is  termed  simple  atrophy:  where  there  is  loss  in  the  number 


38  INTRODUCTION. 

of  such  elements,  it  is  termed  numerical  atrophy.  As  numerical  atro- 
phy must  be  the  result  of  previous  diminution  in  size  in  the  elements 
which  have  disappeared,  it  is  evident  that  simple  atrophy  must 
precede  and  accompany  numerical  atrophy,  the  two  often  being  asso- 
ciated, though  simple  atrophy  may  occur  alone.  It  must  be  patent 
that  numerical  atrophy  is  of  the  more  serious  character,  as,  when 
the  histological  elements  of  a  part  are  destroyed  the  condition  will 
be  permanent,  unless  new  cells  are  created — something  not  likely  to 
occur — while  in  simple  atrophy,  under  favorable  circumstances,  the 
elements  may  be  restored  to  their  former  condition. 

A  familiar  example  of  simple  atrophy  is  loss  of  the  subcutaneous 
adipose  tissue  which  attends  general  emaciation.  The  adipose  tis- 
sue here  consists  of  connective-tissue  cells  filled  with  fat.  When 
the  fat  is  absorbed,  the  cells  diminish  in  size,  the  general  bulk  of 
the  body  thus  becoming  wasted.  In  a  similar  manner  the  fat  may 
be  removed  from  the  connective-tissue  throughout  the  body,  and 
portions  of  the  contents  of  cells  of  other  structures,  thus  resulting  in 
diminution  of  bulk.  The  cells  of  glandular  organs  may  thus  be 
involved,  suoli  parts  as  the  liver,  kidneys,  mammary  glands,  spleen 
testicles,  lymphatic  glands,  and  other  organs  becoming  wasted  in 
size  in  this  manner.  The  primitive  fasciculi  of  muscles  may  also  be 
thus  affected,  this  being  common  in  the  heart  and  voluntary  mus- 
cles, during  wasting  diseases.  When  restitution  occurs,  there  must 
be  an  increase  in  the  nutritive  activity  of  these  parts,  and  supply  of 
more  nutritive  material. 

In  numerical  atrophy,  the  loss  of  substance  and  lack  of  nutritive 
supply  results  in  molecular  disintegration  of  the  elementary  cells,  this 
usually  occurring  in  circumscribed  areas,  and  only  a  granular  debris 
finally  remains,  to  mark  the  focus  of  atrophic  action.  This  differs 
from  necrosis,  in  that  the  substance  is  absorbed  and  carried  away 
gradually  in  atrophy,  while  in  necrosis  there  is  such  rapid  death 
of  the  part  that  its  substance  remains  as  a  foreign  body,  subject  to 
immediate  expulsion,  the  granular  debris  of  atrophy  still  remaining 
a  part  of  the  living  tissue,  though  its  bulk  be  lessened  and  its  func- 
tion destroyed. 

Atrophy  may  be  general  or  partial.  In  general  atrophy,  all  the 
organs  and  tissues,  to  a  greater  or  less  extent,  are  involved  in  loss 
of  substance,  while  partial  atrophy  is  limited  to  separate  parts. 
General  atrophy  is  usually  simple,  only  the  size  of  histological  ele- 
ments being  involved,  while  partial  atrophy  is  often  numerical,  cer- 
tain histological  elements  being  completely  destroyed. 

A  better  conception  of  the  different  forms  and  conditions  of  atro- 
phy may  be  had  by  considering  the  causes  of  general  and  partial 


ATEOPHY.  39 

atrophy.  These  may  be  summed  up  under  three  general  heads:  (1) 
Deficient  supply  of  nutritive  material;  (2)  excessive  waste;  and  (3) 
impaired  nutritive  activity, 

Any  condition  of  affairs  which  interferes  with  the  supply  of 
sufficient  nourishment  is  soon  followed  by  wasting  of  the  entire  body. 
Starvation,  insufficent  food  supply,  soon  manifests  itself  by  emaciation 
and  general  atrophy  of  all  the  tissues  of  the  body,  the  adipose  tissues 
first  wasting,  the  firmer  structures  being  involved  later.  Conditions 
of  the  system  which  operate  to  interfere  with  the  appropriation  of 
food  bring  about  the  same  result,  as,  for  instance,  obstruction  to  the 
passage  of  food  into  the  stomach  or  intestines,  such  as  stricture,  or 
interference  with  the  absorption  of  the  food  after  digestion,  as 
disease  of  the  mesenteric  glands,  liver,  etc.  Any  condition  which 
prevents  proper  nutritive  pabulum  from  reaching  the  blood  in  a 
digested  condition  will  cause  general  atrophy. 

Excessive  waste  of  normal  tissue-elements  also  results  in  general 
atrophy.  We  observe  this  in  continuous  hemorrhages,  in  diabetes, 
albuminuria,  prolonged  and  profuse  suppuration,  and  in  the  destruc- 
tion of  tissue  which  attends  febrile  disease. 

Impaired  nutritive  activity  is  the  usual  cause  of  the  atrophy  of  old 
age — senile  atrophy.  As  age  advances  the  plastic  power  of  the 
tissues  diminishes;  and  they  are  unable  to  appropriate  nutritive 
material  vigorously;  and  there  is  also  enfeebled  circulation.  The 
result  is  a  general  wasting  of  the  tissues,  slow  but  permanent. 

These  causes  are  usually  combined  in  the  bringing  about  of 
emaciation.  For  example,  in  the  marasmus  of  phthisis  there  is 
excessive  waste  from  the  colliquative  sweats  and  profuse  expectora- 
tion, the  digestive  organs  are  so  involved  that  little  food  is  con- 
sumed, while  the  assimilative  powers  are  impaired.  And  so  with 
almost  every  other  condition  of  general  atrophy  except  starvation 
from  lack  of  food.  Disturbance  of  one  organ  or  function  begets  dis- 
turbances of  others,  and  a  chain  of  circumstances  results  from  the 
combination,  all  of  which  tend  toward  loss  of  tissue — general 
atrophy. 

The  causes  of  partial  atrophy  are:  (1)  Imperfect  supply  of  blood; 
(2)  diminished  functional  activity;  (3)  increased  functional  activity;  (4) 
the  action  of  certain  drugs;  (5)  nervous  influence;  and  (6)  inflammation. 

Imperfect  supply  of  blood  is  usually  the  result  of  pressure  upon 
the  arteries  concerned  in  carrying  nutritive  material  and  distributing 
it  to  the  affected  part.  This  may  arise  at  a  distance  from  the  atro- 
phied organ  or  area,  from  pressure  to  a  main  trunk  from  the  growth 
of  a  tumor  or  contraction  of  cicatricial  tissue,  or  it  may  be  due  to 
the  proliferation  of  connective- tissue  elements  of  the  stroma  of  an 


40  INTRODUCTION. 

organ  with  subsequent  contraction,  resulting  in  strangulation  of  the 
normal  circulation.  Direct  pressure  upon  a  part  which  is  not  yield- 
ing may  result  similarly,  as  when  an  aneurism,  or  even  an  arterial 
trunk,  presses  against  the  surface  of  a  bone,  causing  indentation  and 
atrophy  of  its  tissue  in  that  particular  place.  The  pressure  of 
hydrocephalus  within  the  cranium  causes  thinning  of  the  cranial 
bones ;  that  of  retained  secretion  in  the  bladder  from  urethral  obstruc- 
tion, atrophy  of  the  kidney,  etc. 

Diminished  functional  activity  is  a  common  cause  of  atrophy.  Dis- 
use of  the  muscles  of  locomotion  is  soon  followed  by  atrophy  of 
these  parts.  Let  a  person  remain  in  bed  for  a  few  weeks,  even  when 
in  fair  bodily  health,  and  the  muscles  of  the  lower  extremities 
become  very  much  lessened  in  size.  The  disuse  of  foetal  organs 
which  follows  the  changed  conditions  of  birth  results  in  rapid  and 
complete  destruction  of  the  functional  capacity  of  the  ductus  arteri- 
osus,  the  umbilical  arteries  and  veins,  and  the  Wolffian  bodies.  The 
involution  of  the  uterus  after  parturition,  and  the  wasting  of  the 
lower  jaw  after  loss  of  the  teeth,  are  other  examples  of  physiological 
atrophy  from  disuse. 

Groups  of  paralyzed  muscles  soon  atrophy,  though  in  some  cases 
this  may  not  be  due  to  loss  of  function  alone,  trophic  influences 
being  brought  more  or  less  to  bear;  for  there  are  evidently  certain 
nervous  filaments  which  connect  nutritional  centers  in  the  spinal 
cord  with  every  part  of  the  body. 

After  establishment  of  an  artificial  anus,  the  rectum  becomes 
atrophied,  often  dwindling  away  to  a  mere  fibre-cellular  cord.  Sec- 
tion of  nerve  trunks  is  followed  by  atrophy  of  the  distal  extremity, 
and  atrophy  of  the  optic  nerve  follows  enucleation  of  the  eye  or 
destruction  of  its  function-elements. 

Increased  functional  activity  is  occasionally,  though  rarely,  a  cause 
of  atrophy.  Some  glandular  structures,  especially  that  of  the  tes- 
ticle, dwindles  away  as  a  result  of  excessive  activity. 

Certain  drugs  cause  atrophy  of  particular  organs.  Iodine  causes 
more  or  less  wasting  of  the  lymphatic  glandular  system;  bromine, 
'of  the  testicles;  and  fucus  vesiculosus  and  the  juice  of  phytolacca 
berries  are  said  to  produce  atrophy  of  adipose  tissue. 

The  atrophy  which  results  from  inflammation  is  usually  due  to 
the  organization  of  new  fibrous  tissue  in  the  stroma  of  organs,  the 
contraction  of  which  compresses  the  circulation  and  thus  cuts  off  or 
impedes  blood  supply  to  such  an  extent  as  to  deprive  the  affected 
parts  of  normal  nourishment.  Dwindling  away  of  the  elements  of 
an  affected  organ  therefore  results,  and,  when  this  is  a  vital  organ, 
like  the  liver  or  kidney,  fatal  results  follow. 


DEGENERATIONS.  41 

There  is  often  the  association  of  fatty  degeneration  with  atrophy, 
the  same  condition — interference  with  normal  supply  of  nutrition — 
operating  to  bring  about  both  these  results  at  once.  During  senility 
both  conditions  are  often  associated,  atrophy  and  fatty  degeneration 
occurring  together  as  results  of  limited  blood  supply  to  the  affected 
part.  Brown  atrophy  of  the  heart  is  an  instance  of  the  association 
of  these  conditions.  It  consists  of  gradual  atrophy  of  the  muscular 
fibers,  attended  by  the  formation  of  brownish  yellow  or  blackish 
pigment.  The  fibers  are  often  at  the  same  time  the  seat  of  fatty 
degeneration.  Association  of  atrophy  and  fatty  degeneration  are 
not  uncommon  in  pulmonary  tuberculosis,  pernicious  anaemia,  and 
other  wasting  diseases. 

It  is  not  probable  that  all  cases  of  atrophy  may  be  benefited  by 
treatment;  indeed,  comparatively  few  of  them  can  be  improved.  Cor- 
rection of  the  conditions  which  lead  to  them  is  the  first  thing  to  be 
thought  of,  though  this  is  not  always  possible.  In  some  cases 
the  condition  may  be  modified,  at  least,  by  the  judicious  use  of  elec- 
tricity and  massage,  these  measures  encouraging  the  circulatory  and 
nutritional  activities.  The  action  of  certain  drugs  improves  the 
plastic  power  of  atrophied  parts,  though  the  subject  requires  a  fur- 
ther investigation.  For  example,  sabal  serrulata  influences  the 
mamary  glands  and  testes  in  this  manner,  increasing  their  size  and 
functional  power.  Bryonia  exerts  a  similar  influence  upon  the  retina 
and  optic  nerve.  Collinsonia  thus  influences  the  rectum,  and  rham- 
nus  calif ornica  the  muscles. 


111.   DEGENERATIONS. 

THE  degenerations  differ  from  atrophy,  in  that  there  is  altera- 
tion in  the  quality  of  the  cells  of  an  affected  part  which  not  only 
impairs  but  destroys  their  functional  capacity.  Complete  annihila- 
tion of  a  part  may  thus  result,  its  character  being  histologically  as 
well  as  functionally  altered. 

Two  kinds  of  degeneration  occur,  which  are  described  as  (1)  met- 
amorphoses, and  ( 2 )  infiltrations. 

The  metamorphoses  are  the  result  of  a  direct  change  in  the  albu- 
minoid constituents  of  the  cells  of  a  part,  by  which  they  are  con- 
verted into  a  new  material.  This  is  attended  by  a  complete  destruc- 
tion of  the  intercellular  substance,  which  softens  and  loses  its 
normal  characteristics,  the  entire  normal  structure  of  the  part  being 
annihilated. 

The  infiltrations  are  characterized  by  the  infiltration  of  new  ele- 
ments into  the  cells  of  a  part,  which  displace  the  normal  elements  to 


42 


INTRODUCTION. 


CLOUDY  SWELLING. 


a  certain  extent,  but  which  does  not  destroy  them  nor  interfere  com- 
pletely with  their  functions.  The  intercellular  substance  is  not  usu- 
ally destroyed,  and  the  affected  part  may  retain  a  modified  portion  of 
its  structural  and  functional  individuality. 

PARENCHYMATOUS  DEGENERATION. 

THE  common  name  for  this  form  of  degeneration  is  "cloudy 
swelling,"  though  it  is  otherwise  known  as  albuminous,  serous,  and 
granular  degeneration.  Ifc  consists  of  a  swell- 
ing of  the  anatomical  elements  of  portions  of 
the  body,  accompanied  by  granulation  of  the 
cell-contents,  and  disappearance  of  the  nuclei. 
The  granules  resemble  fat-granules  in  appear- 
ance, but  differ  from  them  by  being  soluble  in 
acetic  acid,  and  insoluble  in  alcohol  or  ether. 
The  parenchyma-cells  of  important  organs, 
such  as  the  liver,  kidneys,  heart,  etc.,  are 
especially  prone  to  such  a  condition,  the  organs 
becoming  swollen,  pale,  and  friable.  Cells 
which  undergo  this  degeneration  are  not  necessarily  destroyed,  a 
gradual  return  of  their  integrity  following  favorable  constitutional 
conditions. 

This  form  of  degeneration  attends  many  severe  acute  diseases, 
the  infectious  fevers  being  especiafly  prone  to  it.  All  soft  tissues 
participate,  though  the  abdominal  and  thoracic  organs  and  kidneys 
suffer  most.  It  may  follow  poisoning  from  arsenic,  phosphorus,  or 
the  mineral  acids. 

Cloudy  swelling  occurs  especially  in  epithelial  elements.  The 
accompanying  illustration  represents  progressive  stages  of  degenera- 
tion of  this  character  in  the  epithelial  cells  of  the  urinary  tubules,  in 
acute  tubal  nephritis. 

FATTY  INFILTRATION. 

Fatty  infiltration  consists  of  infiltration  of  fat  into  cells  in  such 
a  manner  as  to  displace  the  nucleus  and  crowd  aside  other  elements 
without  destroying  their  functions.  The  fat  accumulates  within 
the  affected  cells  as  distinct  globules,  displac- 
ing the  nucleus  and  protoplasm,  though  after 
it  is  removed  by  absorption  the  cell  remains  in 
a  normal  condition.  Fatty  infiltration  occurs 
as  a  normal  process,  due  to  the  presence  of 
more  fatty  material  in  the  body  than  is  required 
FATTY  INFILTBATIOH.  ^or  physiological  purposes,  the  excess  then 
being  stored  in  the  connective  tissue  for  future  use.  The  favorite 


DEGENERATIONS.  43 

points  for  fatty  infiltration  are  adjacent  to  the  radicles  of  the  nutri- 
ent vessels. 

In  fatty  infiltration  the  fat  is  derived  from  the  oleaginous,  saccha- 
rine, and  nitrogenous  principles  of  the  food,  instead  of  from  the 
affected  tissues  themselves,  as  in  fatty  metamorphosis. 

Abnormal  fatty  infiltration  occurs  in  obesity  and  emaciation. 
In  the  one  instance,  there  is  more  fat  in  the  body  than  the  natural 
oxidizing  powers  are  capable  of  destroying;  and,  in  the  other,  the 
oxidizing  processes  are  so  interfered  with  that  the  fat,  in  even  a 
small  amount  of  food,  is  incompletely  oxidized,  accumulation  of  fat 
in  the  cells  resulting.  Thus,  in  chronic  phthisis,  we  may  find  that 
fatty  infiltration  is  often  present. 

The  accompanying  illustration  represents  the  gradual  infiltration 
of  a  cell  with  fat,  with  displacement  of  the  normal  cell-contents. 

FATTY  DEGENERATION. 

FATTY  degeneration,  or  fatty  metamorphosis,  differs  from  fatty 
infiltration  in  that  there  is  an  alteration  of  the  normal  cell-contents 
instead  of  infiltration  of  fat,  the  normal  cell-elements  thus  being 
destroyed,  the  albuminous  constituents  of  the  tis- 
sues themselves  being  converted  into  fat. 

Thus  the  cell  furnishes  the  fat  for  its  own  sub- 
stance, minute  granules  or  globules  of  fat  making 
their  appearance  in  the  cell,  the  entire  protoplasm 
finally  becoming  converted  into  fat-granules. 

States  which  interfere  with  the  proper  quality  of 

FATTY  DEGENERATION    . ,        ,  ,         ,  ..  -j?ii 

OP  THE  HEABT.  the  blood,  so  that  the  tissues  are  imperfectly  nour- 

ished, as  in  pulmonary  tuberculosis,  protracted  anaemia,  and  other 
wasting  diseases,  tend  to  general  fatty  degeneration,  certain  tissues, 
such  as  the  heart,  liver,  kidneys,  walls  of  arteries,  and  voluntary 
muscles,  being  especially  prone  to  fatty  deposits. 

The  metamorphosis  of  fatty  degeneration  begins  in  the  proto- 
plasm of  the  cells,  outside  the  nucleus — though  this  is  soon  involved 
and  broken  up — as  transformation  of  minute  particles  of  the  albumin- 
oid substance  into  fat-granules.  These  multiply,  and  the  destruc- 
tive change  invades  the  nucleus,  transforming  its  substance  into 
fatty  granules  and  obliterating  its  limiting  membrane.  As  fatty 
granulation  progresses  in  the  cell,  its  entire  contents  become  fatty, 
the  change  involving  the  cell  wall  and  intercellular  substance. 
Neighboring  cells  becoming  involved  and  the  intercellular  structure 
becoming  disorganized,  the  fatty  remains  of  numerous  cells  may  coa- 
lesce to  form  fatty  masses,  which  exist  at  the  expense  of  the  nor- 
mal tissue  invaded. 


44  INTRODUCTION. 

The  accompanying  cut  represents  a  section  of  the  cardiac  muscle 
which  has  undergone  fatty  degeneration.  The  striaB  are  seen  broken 
up  in  places,  their  substance  having  been  converted  into  fatty  gran- 
ules, which  are  distributed  more  or  less  profusely  throughout  the 
structure. 

Parts  which  are  insufficiently  supplied  with  blood  on  account  of 
pressure  upon  nutrient  arteries  are  prone  to  this  form  of  degenera- 
tion, the  coronary  arteries  being  partially  occluded  by  atheromatous 
products  when  fatty  degeneration  of  the  cardiac  muscle  occurs. 

Separation  of  nerves  results  in  fatty  degeneration  of  the  distal 
extremities.  Organs  which  have  become  atrophied  from  disuse  are 
prone  to  fatty  degeneration,  as  a  result  of  diminished  blood-supply 
and  imperfect  oxidation.  The  tissues  of  old  persons  are  liable  to 
such  changes,  due  to  impoverishment  of  blood-supply,  the  metamor- 
phosis occurring  in  the  cartilages,  cornea  (arcus  senilis)  and  lens 
(cataract),  and  in  the  brain  (cerebral  softening). 

MUCOID  AND  COLLOID  DEGENERATION. 

THESE  forms  of  degeneration  resemble  each  other  so  much  that 
they  are  very  liable  to  be  confounded,  though  there  is  a  material 
difference  in  the  nature  of  the  two.  Mucoid  degeneration  is  more 
liable  to  affect  the  intercellular  substance,  while  colloid  degeneration 
is  more  liable  to  affect  the  cellular  elements.  Colloid  material  differs 
from  mucin,  the  product  of  mucoid  degeneration,  chemically,  in  con- 
taining sulphur,  and  in  not  being  precipitated  by  acetic  acid. 

Mucoid  Degeneration.  This  process  has  its  normal  type  in  the 
secretion  of  mucus  by  the  mucous  follicles,  the  epithelial  cells  here 
being  converted  into  mucin  and  cast  off,  forming  a  transparent  gelat- 
inous substance,  familiar  to  every  observer.  Mucoid  tissue  consti- 
tutes the  earliest  form  of  every  foetal  structure,  a  higher  development 
being  taken  on  later,  though  the  mucoid  material  persists  in  the 
vitreous  humor  of  the  eye  throughout  life,  and  is  familiar  to  the 
obstetrician  in  the  structure  of  the  umbilical  cord. 

Other  structures  than  the  mucous  membrane  may  develop  this 
substance  (mucin)  under  abnormal  conditions.  Connective  tissue, 
cartilage,  bone,  marrow,  adipose  tissue,  and  sarcoma  (a  new  growth), 
may  undergo  abnormal  mucoid  softening.  This  is  liable  to  occur 
simultaneously  in  considerable  patches,  the  basement  membrane 
becoming  involved,  the  fibrous  structure  contained  in  it  being  con- 
verted into  homogeneous  material.  The  tissue-cells  may  then  persist, 
undergo  fatty  degeneration,  or  partake  of  the  mucoid  change. 

Mucoid  degeneration  most  frequently  occurs  in  cartilage,  espe- 
cially the  intervertebral  and  costal  cartilages  of  old  people.  Con- 


DEGENERATIONS.  45 

siderable  cavities  of  cyst-like  accumulations  of  mucin  may  be  found 
here  as  the  result  of  such  change.  The  myxomata  or  inucoid  tumors 
consist  of  this  material.  The  causes  of  this  form  of  degeneration 
are  unknown. 

Colloid  Degeneration.  This  differs  from  mucoid  degeneration  in 
the  fact  that  the  cells  are  the  parts  especially  involved.  The  albu- 
minoid material  in  the  cells  becomes  converted  into  colloid,  this 
first  appearing  as  minute  lumps  in  the  interior  of  the  cell,  which 
gradually  increase  in  size,  crowding  the  nucleus  aside,  and  finally 
representing  the  entire  cell  structure.  This  constitutes  a  colloid 
mass,  which  swells  up  and  bursts  the  cell  wall,  to  coalesce  with  con- 
tents of  neighboring  cells  which  have  undergone  a  similar  change. 
This  coalescence  results  in  the  formation  of  cysts  or  accumulations 
of  greater  or  less  size,  of  a  gelatinous,  shining,  transparent  material, 
resembling  cooked  sago  in  appearance,  though  of  a  yellowish  color  and 
tolerably  firm  consistence. 

Colloid  changes  occur  most  frequently  in  enlargement  of  the  thy- 
roid and  lymphatic  glands,  in  the  choroid  plexus,  and  especially  in 
the  new  growths. 

AMYLOID  DEGENERATION. 

THIS  term,  with  our  present  knowledge,  is  evidently  a  misnomer, 
though  when  Yirchow  applied  it  he  supposed,  from  the  resemblance 
of  the  chemical  reaction  between  this  substance  and  iodine  to  that 
between  iodine  and  starch  and  cellulose  and  iodine,  that  it  belonged 
chemically  to  the  starchy  group,  and  named  it  "amyloid"  (like 
starch).  But  later  investigators  have  demonstrated  that  the  sub- 
stance of  amyloid  degeneration  is  a  nitrogenous  formation,  an  albu- 
minoid, and  not  in  any  way  related  to  starch. 

Its  reaction  with  certain  matters,  however,  is  remarkable.  When 
a  solution  of  iodine  is  added  to  it,  it  becomes  colored  mahogany 
brown,  the  surrounding  unaffected  tissue  appearing  pale  yellow. 
Iodine  and  sulphuric  acid  impart  a  blue  color  to  it,  and  methyl-blue 
and  gentian  a  bright  red  or  pink  color. 

To  the  naked  eye,  the  morbid  deposit  appears  semi-translucent, 
waxy,  or  lardaceous — resembling  the  fatty  portion  of  fried  bacon. 
When  it  invades  internal  organs  extensively,  they  become  swollen, 
resistant  to  pressure,  increased  in  weight,  their  capsules  being  tense, 
dry,  and  pale.  When  it  invades  the  spleen,  the  cut  or  broken  surface 
resembles  boiled  sago,  and  the  condition  has  been  commonly  termed 
"sago  spleen."  The  liver,  kidneys,  lymphatic  glands,  serous  mem- 
branes, mucous  membrane  of  the  alimentary  canal,  blood-vessels,  and 
connective  tissue,  are  all  liable  to  the  invasion  of  this  degeneration. 

It  accompanies  depraved  states  of  the  blood  due  to  prolonged 


46  INTRODUCTION. 

disease,  such  as  tubereulosis,  leukicmia,  suppuratiou  of  bone,  chronic 
dysentery,  etc.,  though  it  is  absent  in  cancer.  It  occasionally  follows 
iuflainmmtory  action.  It  is  very  liable  to  develop  during  senility, 
without  other  apparent  provoking  cause. 

The  character  of  the  deposit  is  not  yet  well  determined.  The 
consensus  of  opinion  seems  to  be  in  favor  of  the  belief  that  the 
deposit  is  fibrin  which  becomes  separated  from  the  blood  by  meta- 
morphosis or  infiltration.  Color  is  added 
to  this  theory  by  the  fact  that  the  disease 
nearly  always  begins  about  the  capillaries 
and  minute  arteries,  the  deposit  appearing 
in  the  peri-endothelial  fibrous  tissue  coating 
the  outer  side  of  the  endothelial  wall.  If 
this  occur  in  internal  organs  in  which  the 
parenchyma-cells  lie  within  capillary  plex- 
uses, the  organ-cells  may  remain  unaffected 
SECTION  OF  AMYLOID  KIDXEY.  while  the  capillaries  are  extensively 

a,  Norina  capillary  loop.  invrVIvArl         Tf    tlii«    nppnr    in     tlift    livpr      flip 

b.  Amyloid  capillary  loop.  IBTOITBO.        11    U11S    OCCUT    in    fBf      liver,     1 

d,  Hyraunleffica8utm  liver  cells  may  remain  unchanged  between 
ZSSuSSfSSS:  the  masses  of  amyloid  material  which  are 

e,  Loosened  fatty  epithelium.     aepOSited    about    the    capillary    plexuses 
surrounding    them.     So  with  the  kidney;    the    amyloid  deposit    is 
massed  about  the  capillaries  of  the  glomeruli  and  other  minute  ves- 
sels, while  other  histological  elements  remain  unchanged;  though  in 
some  instances  the  connective   tissue  of  a  part,  such  as  the  spleen 
and  lymphatic  glands,  may  suffer  most. 

Fatty  changes  are  liable  to  attend  amyloid  degeneration,  this 
being  due  to  obstruction  and  compression  of  the  blood-vessels. 

Certain  concretions  called  amyloid  bodies  appearing  normally  in 
the  brain,  prostate  gland,  and  vesiculse  seminales,  afford  the  same 
color  reactions  with  iodine,  and  iodine  and  sulphuric  acid.  They 
bear  no  relation  to  this  form  of  degeneration,  and  are  probably  a 
normal  accompaniment  of  advancing  years. 

CALCAREOUS  DEGENERATION. 

THIS  is  an  infiltration,  not  a  metamorphosis.  It  consists  of  the 
infiltration  of  normally  soft  tissues  with  calcareous  and  magnesian 
salts,  rendering  them  brittle,  chalky,  and  to  the  touch,  gritty.  It 
occurs  as  a  normal  process  when  calcareous  elements  are  deposited 
in  cartilage  preparatory  to  the  formation  of  bone,  but  here  the  infil- 
tration is  succeeded  by  organization  of  the  calcareous  material  into 
cells  and  bone  tissue,  while  in  degeneration,  the  calcareous  material 
remains  as  an  infiltration,  destroying  the  elasticity  of  the  part  and 
impeding  the  function  of  the  cells  invaded. 


DEGENERATIONS.  47 

Both  cellular  and  intercellullar  elements  may  be  infiltrated, 
though  the  first  portion  to  be  involved  usually  is  the  intercellular 
structure.  Calcareous  degeneration  may  be  a  final  termination  of 
fatty  degeneration,  and  a  very  favorable  one  when  vital  organs, 
as  the  lungs,  are  involved,  as,  when  this  change  has  occurred,  it 
becomes  a  permanent  one,  further  degeneration  and  breaking  down 
being  arrested.  In  such  cases  the  calcareous  infiltration  may  be 
regarded  as  the  lesser  of  two  inevitable  evils  and  welcome  as  a  favor- 
able termination  of  destructive  action. 

When  the  arteries  become  involved,  much  more  serious  conse- 
quences are  liable  to  follow,  as  obstruction  to  these  organs  from 
inelasticity  aud  narrowing  of  their  lumen  is  certain  to  follow,  with 
consequent  destruction  of  parts  supplied  with  blood  through  them. 
Atheromatous  changes  in  the  arteries  are  liable  to  be  followed  by 
this  state,  especially  about  the  aorta  and  the  arteries  of  the  extrem- 
ities, the  middle  coat,  and  finally  the  entire  structure,  becoming 
calcified.  Senile  gangrene  is  thus  a  common  result  of  this  condition. 

Calcareous  degeneration  may  occur  under  two  different  circum- 
stances or  influences.  In  the  one  there  appears  to  be  a  perversion 
of  the  plastic  forces,  by  which  the  normal  calcareous  elements  of 
bone  are  deposited  in  an  aberrant  manner,  or  else  there  is  an  excess 
of  calcareous  material  in  the  blood,  many  organs  being  simultane- 
ously involved,  such  as  the  kidneys,  lungs,  stomach,  intestines,  dura 
mater,  and  liver.  This  may  occur  in  osteomalacia,  where  there  is  an 
insufficient  amount  of  lime  in  the  bones  to  render  theia  normally 
firm.  In  the  other  condition  there  has  been  previous  disease  of  the 
parts  infiltrated,  the  degeneration  being  a  passive  process  due  to  the 
inactivity  of  the  function-elements  of  affected  parts.  This  form  is 
that  usually  occurring  in  sei.ile  subjects. 

The  infiltration  usually  consists  of  carbonates  an  1  phosphates  of 
calcium,  with  a,  small  quantity  of  the  magnesium  salts.  When  treated 
with  dilute  mineral  acids,  there  is  bubbling  of  gases  at  first,  and  final 
dissolution  of  the  calcareous  material,  the  part  regaining  its  elasticity. 

PIGMENTATION. 

INFILTRATION  of  the  tissues  with  haemoglobin  causes  more  or  less 
marked  staining,  which  has  been  classed  among  the  degenerations 
under  the  name  of  "pigmentary  degeneration,"  when  the  haemoglo- 
bin becomes  converted  into  hsematoidin,  and  is  permanently  fixed. 
Many  cases  of  extravasation  of  blood  are  followed  by  a  tempo- 
rary staining  of  the  tissues,  but  the  coloring  material  is  in  a  con- 
dition to  be  absorbed,  and  is  soon  taken  up  and  carried  away.  But 
the  haemoglobin  remains,  in  other  cases,  and  becomes  converted 


48  INTRODUCTION. 

into  a  granular  or  crystalline  substance,  hsematoidin,  which  remains 
permanently  fixed,  staining  the  tissues. 

Pigmentation,  of  itself,  is  not  a  serious  condition ;  and  when  it 
affects  the  skin,  it  is  a  sign  that  some  local  or  constitutional  dis- 
turbance has  been  at  work  to  bring  about  destruction  of  the  red 
blood-corpuscles  and  liberation  of  their  coloring  material.  Certain 
cachectic  states  are  especially  prone  to  be  followed  by  permanent  pig- 
mentation of  some  of  the  tissues.  Chronic  malaria  is  ofle  of  these, 
and  the  fairest  complexion  is  liable  to  be  permanently  browned  in 
spots  and  sallowed,  after  a  prolonged  attack  of  this  disease. 

The  tissues  of  the  liver,  kidneys,  stomach,  and  other  internal 
organs  may  be  thus  infiltrated  after  chronic  atrophic  local  affections 
of  these  parts,  the  organs  assuming  a  darkened  color,  and  thus 
remaining  during  the  remainder  of  life,  though  such  diseases  are 
usually  fatal,  not  because  the  pigmentation  is  a  serious  matter,  but 
because  the  causes  which  brought  it  about  have  also  conspired  to 
effect  serious  degenerative  changes  in  vital  organs. 

The  coloring  material  observed  in  lung-tissue  is  not  usually  of 
this  character,  as  here  minute  particles  of  carbon  are  inhaled  from 
the  atmosphere  and  taken  up  by  the  cells  of  the  mucous  membrane 
lining  the  respiratory  passages,  and  there  permanently  fixed.  This 
has  been  termed  a  normal  staining  by  some,  and  it  would  seem  that 
this  is  proper,  seeing  that  it  is  universally  present  in  healthy  lungs. 
However,  without  combustion  of  wood  or  coal  these  particles  would 
not  be  present  in  the  air,  and  the  lungs  would  probably  be  free  from 
the  coloring  matter.  Sometimes  this  coloring  is  accompanied  by 
true  pigmentation,  the  result  of  inflammatory  extravasation  and  other 
agencies,  tending  to  fixation  of  haBmatoidin  in  the  pulmonary  tissues. 
Staining  of  the  tissues  observed  in  subjects  who  have  taken  nitrate 
of  silver  for  a  long  time  is  due  to  the  deposit  of  particles  of  silver, 
and  not  to  true  pigmentation. 

NECROSIS. 

NECROSIS  is  the  term  applied  to  local  death  of  animal  tissues. 
This  may  occur  from  a  variety  of  causes,  and  under  a  wide  diversity 
of  conditions.  Whether  it  affects  a  single  cell,  group  of  cells,  or  an 
entire  organ,  complete  suspension  of  nutrition  aud  function  follows, 
and  the  necrosed  tissue  begins  a  process  of  permanent  dissolution 
aud  disorganization. 

If  the  amount  of  necrosed  tissue  be  small,  and  recuperative 
processes  active,  the  disintegration  may  be  molecular,  the  dead  mate- 
rial being  gradually  absorbed  and  its  place  supplied  by  normal 
structure.  When  somewhat  more  extensive  «nd  the  destruction 
more  rapid,  the  breaking  down  may  result  in  excavations,  which  are 


DEGENERATIONS.  49 

afterward  filled  with  fibrous  or  cicatricial  tissue.  When  an  exten- 
sive area  of  external  soft  tissue  is  involved,  an  obvious  mass  of  dark- 
ened tissue — stained  by  infiltration  with  liberated  haemoglobin — 
appears,  and  is  finally  separated  in  a  mass,  ihe  necrosed  i  ortion 
constituting  a  splmcelus,  or  shugh,  the  condition  being  commonly 
known  as  '  mortification."  If  a  mass  of  bone-tissue  be  involved 
instead,  the  separated  portion  is  termed  A  sequestrum.  Other  masses 
seated  deeply  in  certain  tissues  may  be  converted  into  cheesy- 
appeariug  bodies  and  become  encapsulated,  the  condition  being 
defined  as  caseation;  or  it  may  become  infilt-ated  with  calcareous 
material,  calcification.  When  caseation  or  calcification  occurs,  the 
condition  may  be  considered  one  of  more  or  less  pronounced 
permanency,  though  destructive  changes  may  occur  later. 

Again,  the  dead  tissue  may  be  absorbed,  leaving  a  cavity  which 
becomes  walled  about  with  fibrous  tissue,  affording  a  space  into 
which  fluids  infiltrate,  the  arrangement  constituting  a  cyst.  This  is 
most  liable  to  occur  when  areas  of  necrosis  are  located  in  the  brain. 

A  peculiar  form  of  necrosis  is  that  which  is  termed  hyaline  or 
coagulation  necrosis.  This  consists  of  the  infiltration  of  necrosed 
masses  with  lymph,  in  which  the  third  corpuscle  has  become  lique- 
fied, fibrlnogen  being  developed,  which  ultimately  welds  the  mass 
firmly  together,  a  further  change  converting  the  necrosed  area  into 
hyaline  material.  This  occurs  in  diphtheria,  waxy  degeneration  of 
muscles,  typhoid,  typhus,  relapsing  fevers,  tubercle,  etc. 

Colliquative  necrosis  is  allied  to  the  coagulative  form,  though  it 
occurs  in  non-inflammatory  conditions,  in  which  the  presence  of  scant 
amount  of  fibrinogen  precludes  coagulation,  the  affected  part  under- 
going disintegration  and  liquefaction,  instead  of  becoming  coagu- 
lated. The  brain  contains  little  coagulable  material,  and  colliqua- 
tive  necrosis  is  liable  to  occur  here  as  a  result  of  deficient  supply  of 
nutrition.  Softening  of  the  walls  of  the  heart  may  also  be  due  to 
colliquative  necrosis  when  previous  fatty  degeneration  has  destroyed 
the  muscular  structure  to  great  extent,  necrosis  finally  being  due  to 
continued  diminishing  of  the  supply  of  blood  resulting  from  increas- 
ing obstruction  of  the  coronary  arteries. 

The  causes  of  necrosis  may  be  divided  into  two  classes :  ( 1 )  Local 
injuries,  and  ( 2 )  arrest  of  nutrition. 

Local  injuries  may  be  due  to  mechanical  or  chemical  causes;  to 
inflammatory  action ;  to  long-continued  febrile  action  inducing  extreme 
cloudy  degeneration  in  internal  structures  ;  to  the  poisonous  influence 
of  microbes,  as  in  erysipelas,  diphtheria,  hospital  gangrene,  etc. 

Arrest  of  nutrition  is  due  to  obstruction  of  the  circulation  from 
various  causes,  such  as  strangulation;  gradual  occlusion  of  arteries 


50  INTRODUCTION 

from  senile  changes;  pressure  from  new  growths;  embolism,  ami 
thrombosis. 

Dry  gangrene  is  usually  the  result  of  necrosis  in  parts  exposed 
to  the  air  where  the  supplying  arteries  are  occluded.  The  arterial 
obstruction  may  be  the  result  of  frost-bite,  of  a  gradual  filling  of  the 
lumen  from  senile  changes  in  the  arterial  walls,  such  as  calcification, 
atheroma,  or  of  embolic  infarction.  The  affected  part  becomes  dark 
and  leathery,  then  hard,  black,  and  brittle.  The  anatomical  elements, 
seen  under  the  microscope,  appear  shrunken  and  withered. 

Moist  gangrene  or  sphacelus  is  mortification  followed  by  putre- 
faction, and  development  of  gases  in  the  affected  part.  This  change 
is  due  to  the  action  of  certain  bacteria  in  the  fluids  of  the  gangrenous 
structure,  which  gain  access  either  through  the  air  or  circulation. 
Increase  of  swelling,  external  blistering,  offensive  odors,  oozing  of 
putrefactive  fluids,  and  disintegration  of  soft  parts  thus  affectod, 
follow  at  an  early  period.  When  bone  becomes  necrosed,  the  process 
of  disintegration  is  more  gradual. 

TUBERCULOSIS. 

TUBERCULOSIS  is  a  condition  characterized  by  the  formation  of 
nodules  or  tubercles  within  various  tissues  of  the  body,  formed  by 
an  aggregation  of  cells,  due  to  proliferation  of  surrounding  tissue- 
elements,  resulting  from  chronic  inflammation  caused  by  the  pres- 
ence of  the  tubercle  bacilli.  They  are  new  growths,  of  low  vitality. 
Tubercles  arise  from  small  cells  which  originate  from  a  meso- 
blastic  membrane  developed  from  connective  tissue,  or  from  the 
endotheliuin  of  blood-vessels  or  lymphatics.  A  focus  of  irritation 

is  set  up  by  the  action  of  the  bacilli  upon 
.  the  tissues,  and  proliferation  and  aggrega- 
*  tion  of  these  elements  result.     Leucocytes 
congregate  about  this  focus,  and  granula- 
tion tissue  is  developed.     Usually  one  or 
more    epitheliod   or  lymphoid  cells   take 
on   a   hyper-plastic  growth,  and,  fed  by 
broken-up  leucocytes,  develop  into  giant 

MIUABY  TDBEBCIJC.  cells,  with  homogeneous  structure,  numer- 

a, Giant ceii.  ous    nuclei,  and   branching   processes. 

b,  Nuclei  of  giant  cell.  ...  -  ,  .,,      ,.     .,          ,, 

c,  Epuheiioid  ceiu.  About  these  are  grouped  epithelioid  cells 

d,  Lymphoid  eel  !•.  .,.  T>-J-  J.-L        L    \  1        • 

and  leucocytes.     Binding  the  tubercle  in 

a  mass  is  usually  a  fibrous  reticulum,  composed  of  the  remains  of 
normal  connective  tissue  which  has  been  distended  and  attenuated 
by  the  proliferated  cells,  and  the  branching  processes  of  giant  cells. 
In  the  meshes  of  this  reticulum  are  the  epithelioid  and  lymphoid 
cells,  and  leucocytes.  An  elementary  tubercle  is  microscopic  in  size, 


DEGENERATIONS.  51 

but  numbers  of  these  become  aggregated  into  larger  masses,  visible 
to  the  naked  eye.  The  tubercle  formation  is  non-vascular,  and  when 
vessels  are  found  in  them  they  are  the  remains  of  preexisting  capil- 
laries, around  which  the  nodulated  growth  has  developed.  Bacilli 
are  distributed  throughout  these  growths,  being  most  numerous 
about  the  central  portion,  where  breaking  down  of  structure  begins. 
They  are  also  found  within  the  giant  cells. 

Tubercles  are  unstable  structures,  and  they  soon  undergo  fatty 
degeneration  in  the  center  from  lack  of  nourishment,  their  non- 
vascular  character  precluding  possibility  of  blood  supply  to  interior 
parts.  Consequently,  the  central  part  undergoes  caseation,  and,  as 
softening  proceeds,  an  abscess-cavity  is  formed  in  the  center,  and  sev- 
eral miliary  tubercles  uniting,  these  cavities  coalesce,  forming  con- 
siderable of  an  opening,  the  walls  of  which  are  studded  with  bacilli. 
Destruction  of  surrounding  tissues  results,  and  as  this  is  progressive, 
destruction  of  the  entire  organ  invaded  follows,  as  well  as  of  other 
parts  to  which  the  bacilli  are  distributed  by  the  circulation.  General 
destruction  and  dissolution  of  the  entire  organism  must  therefore 
finally  result. 

Another  change  which  tubercles  may  undergo  is  that  of  fibrous 
degeneration,  the  common  ending  of  proliferation  of  connective-tissue 
cells  during  chronic  inflammation.  Here  the  tissues  which  surround 
the  tubercle  take  on  fibrous  inflammation,  and  the  newly-developed 
fibrous  tissue  contracts  and  converts  the  growths  into  a  fibrous 
nodule. 

Tuberculosis  is  characterized  by  the  subsequent  invasion  of  vari- 
ous organs  or  the  entire  system,  after  the  process  has  once  begun. 
The  bacilli  enter  the  lymphatics,  usually  making  halts  here  for  a 
time,  but  they  finally  reach  the  blood  through  the  thoracic  duct,  and 
are  distributed  throughout  the  entire  system.  In  some  cases  they 
spread  along  membranes  or  through  structures,  invading  new  parts 
by  continuity. 

Tuberculization  of  tissue  seldom  occurs  without  complication. 
Many  other  morbid  products  are  observable  in  tissues  affected  by 
tuberculosis,  beside  the  typical  tubercle  structure.  The  general  con- 
stitutional depravity  results  in  feeble  digestive  power  and  nutrition, 
tending  to  atrophy  of  all  the  tissues,  especially  the  muscles.  The 
atrophy  may  end  in  degenerative  change,  and  fatty  metamorphosis 
and  infiltration  be  one  of  the  consequences.  Inflammatory  changes 
may  develop  pigmentary  degeneration,  hyaline  necrosis,  and  cloudy 
swelling  of  epithelial  elements.  Tuberculous  material  may  become 
fatty,  calcareous,  or  fibrous.  Hyperplasia  of  connective  tissue  may 
invade  extensive  areas. 


52 


INTRODUCTION. 


Rapid  loss  of  flesh  and  strength,  involving  all  the  functions,  veg- 
etative as  well  as  volitional,  acceleration  of  the  pulse  to  a  hundred 
beats  per  minute  or  near  there,  persistent  elevation  of  the  tempera- 
ture of  the  body  two  or  three  degrees,  hectic  fever  with  colliquative 
sweats,  and  prominent  evidence  of  local  irritation  corresponding  to 
the  part  principally  affected,  are  the  leading  clinical  features  of  the 
condition. 

The  tubercle  bacilli  are  vegetable  microorganisms  about  one-third 
the  diameter  of  a  red  blood-corpuscle  in  length,  and  about  one-sixth 

as  broad  as  long.  They  exist 
in  both  an  active  and  passive 
condition,  rapid  multiplication 
characterizing  their  active  state, 
while  it  is  not  unlikely  that 
they  may  remain  passive  in  the 
system  for  a  long  time,  when 
conditions  unfavorable  to  their 
increase  are  present,  without 
producing  any  disturbance  of 
health.  Indeed,  it  seems  as 
though  it  would  be  almost 

GAC  »vfrwpof  impossible  for  any  one  to  escape 

' 
contamination  ironi  them  under 

such  favoring  circumstances  as  those  which  have  formerly  existed. 
When  they  are  active,  they  present  a  beaded  appearance,  indicating 
the  formation  of  spores,  and  rapid  multiplication.  They  possess  no 
power  of  spontaneous  motion.  They  differ  from  most  other  bacteria 
in  resisting  the  bleaching  influence  of  strong  mineral  acids,  after 
being  colored. 

Various  modes  of  infection  are  known  to  exist.  Hereditary  or  con- 
genital tuberculosis  occasionally  occurs,  though  the  disease  is  rarely 
thus  transmitted.  In  such  cases,  the  bacilli  or  their  spores  pass 
from  the  maternal  circulation,  or  are  transmitted  by  the  male  parent. 
It  is  probable  that  both  avenues  afford  passage  to  the  bacilli  occa- 
sionally, as  they  are  often  found  in  the  blood,  and  have  been  found 
in  the  testes. 

Acquired  tuberculosis  may  result  from  (  1  )  inhalation  ;  (  2  )  inocula- 
tion; and  (3)  from  ingestion  of  tuberculous  food. 

Inhalation  of  the  bacilli  is  the  usual  mode  of  transmission,  as  the 
large  proportion  of  pulmonary  tuberculous  disease  attests.  The 
facts  that  so  many  tuberculous  subjects  are  able  to  be  about  until  a 
short  time  before  death,  and  that  they  have  been  encouraged  to 
remain  in  the  open  air  during  pleasant  weather,  expectorating  upon 


DEGENERATIONS.  53 

the  ground,  where  the  sputum  dries  and  becomes  powdered  dust,  and 
the  bacilli  retaining  their  vitality  for  a  long  time,  to  be  wafted  here 
there  in  the  atmosphere  and  inhaled  by  chance  passers-by,  account 
for  the  readiness  with  which  this  disease  becomes  spread  about. 
Cloisters,  prisons,  and  asylums  are  especially  liable  to  become  thus 
infected,  dust  deposited  upon  furniture,  ceilings,  and  casements, 
being  likely  to  become  contaminated,  long  use  of  such  quarters  by  a 
variety  of  persons  being  almost  certain  to  result  in  the  dissemination 
of  tubercle  bacilli  by  some  one.  Such  places  then  become  perma- 
nant  hotbeds  of  infection,  unless  especial  effort  is  made  to  thoroughly 
disinfect  them,  and  afterwards  confine  tuberculous  cases  to  special 
quarters.  Private  houses  where  the  disease  has  prevailed  are  sub- 
ject to  the  same  danger. 

It  is  patent  that  careful  and  rigorous  measures  to  collect  and 
thoroughly  destroy  the  sputum  of  tuberculous  'patients  will  be  the 
most  successful  method  of  arresting  the  ravages  of  the  disease. 

Inoculation  is  another  common  method  of  transmission.  This 
may  be  developed  through  the  act  of  kissing,  from  the  use  of  con- 
taminated surgical  instruments,  the  hypodermic  syringe,  dental  for- 
ceps, etc.  Butchers  may  be  inoculated  from  the  flesh  or  skin  of 
bovines,  for  the  disease  is  common  among  horned  domestic  cattle. 
Handling  contaminated  meat  is  also  liable  to  result  in  inoculation 
before  cooking,  though  long-continued  heat  destroys  the  bacilli. 
Medical  students  and  practitioners  are  liable  to  inoculation  during 
dissection  and  autopsies  of  tuberculous  persons,  as  well  as  from 
operations  upon  such  subjects.  It  is  asserted  that  the  disease  has 
been  disseminated  among  Jewish  children  from  the  practice  of  suck- 
ing the  fresh  wound  of  the  prepuce  by  tuberculous  operators. 

Infection  from  food  often  occurs.  One  of  the  most  widespread 
causes  of  infection  is  the  use  of  cows'  milk  in  feeding  infants.  It  is 
conceded  that  a  large  percentage  of  cattle  are  tuberculous.  Much  of 
the  condensed  milk,  as  well  as  that  furnished  by  dairymen,  is  therefore 
subject  to  suspicion  of  tuberculous  infection.  Acute  miliary  tubercu- 
losis, a  disease  very  common  among  children,  is  in  all  probability 
the  result  of  such  a  diet,  the  alimentary  canal  offering  a  ready  place 
for  the  introduction  and  dissemination  of  the  bacilli.  A  diet  of 
raw  meat,  such  as  German  sausage  and  raw  beef,  is  also  inimical  to 
safety  on  this  score.  Danger  lurks  in  every  piece  of  raw  beef  as  an 
article  of  food,  though  a  person  may  make  occasional  use  of  it  for  a 
lifetime  and  escape  infection. 

The  treatment  of  tuberculosis  has  proven  almost  a  complete  failure 
from  time  immemorial.  And  recent  times,  despite  the  remarkable 
advances  which  have  been  made  in  the  knowledge  of  its  etiology, 


64  INTRODUCTION. 

have  afforded  us  little  improvement  npon  treatment.  In  spite  of 
the  splendid  achievements  of  Koch,  in  the  discovery  of  the  tubercle 
bacilli,  his  tuberculin  inoculations  have  signally  failed  to  offer  any 
hope  of  beneficial  results.  And  it  is  probable  that  other  researches 
in  this  direction  will  prove  as  fruitless. 

The  majority  of  successful  innovations  in  medicine  have  sprung 
from  humble  sources.  Savants  have  proven  failures,  when  the  suc- 
cessful treatment  of  stubborn  diseases  has  occupied  their  attention. 
Usually  their  reasoning  has  been  too  crude  for  the  intricate  pro- 
cesses of  life  and  correspondence  with  physiological  principles. 
Attempt  to  cure  tuberculosis  by  directing  the  means  toward  the 
extermination  of  the  bacilli  in  the  body,  will  probably  always  prove 
a  failure.  Changes  of  climate,  whereby  the  normal  forces  are 
encouraged,  and  affected  organs  placed  under  more  favorable  circum- 
stances, are  probably  the  best  measures  adopted  by  the  profession 
at  the  present  time,  though  I  believe  there  exist  more  positive 
measures,  which  will  cure  a  large  majority  of  cases  of  pulmonary 
consumption,  after  such  an  advance  has  been  made  that  numerous 
pulmonary  hemorrhages  have  occurred,  if  faithfully  employed.  In 
order  to  prepare  the  reader  for  a  proper  conception  of  these  means, 
I  will  transcribe  the  account  of 

THE  DUKE  OP  WURTEMBERG's  REMARKABLE  CURE  BY  JOHANNES  SCHROTH, 

as  translated  from  the  German  by  Dr.  Wiliiam  Weber,  an  alum- 
nus of  the  California  Medical  College,  and  former  patient  and  pupil 
of  Schroth.  Though  not  literal  in  every  particular,  the  following 
contains  the  gist  of  this  translation : 

"It  is  incredible  how  few  people  there  are  who  think  for  them- 
selves, and  how  often  the  seemingly  most  original  and  independent 
persons  are  found,  upon  close  investigation,  to  be  on  y  the  slaves  of 
the  thoughts  and  opinions  of  others.  Enough  .  .  .  the  sluices 
of  prevalent  opinion  were  opened  against  the  method  of  Schroth, 
and  only  the  great  importance  of  its  new  and  unheard-of  ideas 
could  prevent  the  same  from  being  consigned  to  oblivion.  At  that 
time  cases  were  reported,  such,  for  instance,  as  that  of  the  Duke  of 
Wurteinberg,  which,  from  the  importance  of  the  person  involved, 
commanded  attention.  I  shall  here  give  some  details  of  that  cure, 
which  will  furnish  some  of  the  characteristics  of  Schroth,  as  well  as 
a  better  understanding  of  his  mode  of  treatment 

"Duke  William  of  Wurtemberg,  Captain  of  the  Koyal  Imperial 
Austrian  Regiment  of  the  Line,  No.  45,  in  storming  a  redoubt  of  the 
enemy  at  the  battle  near  Novara  (Italy),  on  March  12th,  1849,  at 
about  noon-time,  was  wounded  one  inch  below  the  patella,by  a  shot 
fired  at  close  range — a  pointed  bullet.  This  injured  the  tendons 


DEGENERATIONS.  65 

and  ligaments  of  the  knee-joint,  perforated  and  splintered  the  tibia, 
separated  the  muscles  of  the  calf,  and  severed  several  arteries,  com- 
ing out  on  the  posterior  surface  of  the  leg. 

"The  Duke,  wounded  in  this  manner,  lay  on  the  battle  field  for 
some  time,  and  later  was  removed  to  a  field-hospital,  and  the  follow- 
ing day,  to  Mortara,  near  the  conquered  redoubt.  The  loss  of  blood 
was  considerable,  but  the  weakness  caused  thereby  rendered  him 
less  sensitive  to  pain.  Nevertheless,  at  the  hospital,  the  Duke  was 
bled  twice. 

"  On  March  28th,  he  was  transported  to  Pavia,  and  suffered  great 
pain  during  the  trip.  Suppuration  had  set  in,  which  spread  over 
the  whole  calf.  Compressing  bandages  sometimes  increased  the 
pain  to  the  point  of  syncope.  Pyrexia  set  in,  and,  in  the  opinion  of 
his  attending  physician,  his  life  was  in  imminent  jeopardy. 

"  On  account  of  the  malarious  climate,  the  Duke  was  removed  to 
Mailand,  and  was  here  taken  charge  of  by  the  Surgeon  in  Chief  of 
the  Royal  Imperial  Lombard  Gendarmerie  Regiment,  the  latter  part 
of  April.  On  May  7th,  a  long  incision  was  made  in  the  calf  to  arrest 
the  progress  of  fistulse  in  that  region,  and  a  progressive  improve- 
ment seemed  to  follow,  for  a  short  time.  About  the  middle  of  June 
the  patient  left  his  bed  for  the  first  time,  but  could  make  no  use  of 
his  leg.  Warm  baths  were  administered  to  him  every  other  day, 
and  he  attempted  to  walk  on  crutches,  and  occasionally  rode  about 
in  a  carriage,  toward  evening. 

"Evidently,  however,  there  was  little  improvement  for  the  follow- 
ing six  weeks,  for  the  pain  increased,  and  the  Duke  left  Mailand  the 
first  of  August  en  route  for  Baden  Springs,  near  Vienna,  for  the  pur- 
pose of  trying  the  effect  of  these  waters  for  relief.  His  condition 
was  now  so  extreme  that  convulsions  occasionally  occurred.  Though 
this  trip  was  signalized  by  excruciating  suffering,  he  improved  some- 
what at  Baden  for  the  first  fortnight,  but  after  the  effects  of  the 
change  passed  away,  his  strength  again  began  to  fail,  and  the  inflam- 
mation and  pain  in  the  diseased  leg  continued  to  increase  with  added 
suffering.  Up  to  this  time  the  patient  had  never  been  able  to  stand 
on  his  diseased  leg.  As  in  Italy,  prominent  surgeons  at  Vienna 
advised  him  to  submit  to  amputation,  but  this  was  obstinately 
opposed  by  the  Duke. 

"His  condition  becoming  continually  worse,  he  went  to  Karlsruhe, 
in  Prussian  Upper  Silesia  (the  place  of  his  birth),  arriving  there 
September  22d,  very  much  exhausted.  An  eminent  surgeon  was 
now  summoned  from  Berlin,  who  proposed  to  remove  the  head  of 
the  tibia;  but  as  the  Duke  was  very  low,  and  as  the  surgeon  could 
not  positively  promise  a  satisfactory  result,  the  proposal  was  rejected. 


56  INTRODUCTION. 

"At  this  desperate  stage  of  affairs,  at  the  advice  of  his  former 
teacher,  Dr.  Merten,  and  against  the  wishes  of  his  family,  the  Prince 
decided  to  go  and  consult  the  naturalist  physician,  Johannes  Schroth, 
ut  Lindewiese,  near  Grafenberg,  whose  reputation  for  wonderful 
success  in  the  treatment  of  similar  troubles  had  long  been  noised 
abroad.  On  November  12th,  he  therefore  lelt  for  Lindeweise,  arriv- 
ing in  an  exhausted  condition  on  the  following  14th. 

"When  Schroth  investigated  the  case,  he  was  appalled  by  the 
appearance  of  the  diseased  leg.  The  knee  was  swollen  to  half  more 
than  its  normal  size,  and  the  swelling  was  hardened  by  hyperplastic 
deposits  in  the  inflamed  structures  and  about  the  fistulous  open- 
ings. The  part  was  extremely  sensitive  and  painful,  and  the  least 
motion  of  the  joint  was  impossible.  The  bone  was  enlarged,  and 
almost  the  entire  tibia  was  found  honeycombed.  Tiie  probe  would 
break  through  the  decomposed  and  softened  bone  at  almost  every 
point  along  its  shaft  and  about  the  tuberosities,  with  the  most  gentle 
pressure.  At  a  depth  of  about  three  inches  from  the  surface,  in  the 
neighborhood  of  the  old  wound,  were  splinters  of  bone,  and  from 
here  fetid  ichor  was  constantly  discharged.  From  above  the  knee 
down  into  the  calf,  enlarged  and  painful  lymphatic  glands  (the  size 
of  a  pigeon's  egg)  were  found.  Continuing  with  the  examination 
Schroth  found  the  liver  and  spleen  enlarged :  a  condition  he  ascribed 
to  laguna  fever,  from  which  the  patient  had  suffered  while  in  Venice. 

"The  difficulty  was,  not  only  to  cure  the  local  affection,  but  to 
invigorate,  if  possible,  the  broken-down  constitution.  To  do  this 
Schroth  thought  it  necessary  that  an  excretion  of  morbid  matter 
from  the  system  should  take  place,  and  formation  of  new  and  healthy 
blood  be  induced.  It  was  his  idea  that  only  under  such  circum- 
stances could  the  diseased  organs  be  regenerated  to  normal  condi- 
tions. The  physician  present,  educated  in  the  principles  of  the 
scientific  schools,  could  not  believe  in  a  regular  treatment  without 
remedies,  and  remonstrated  with  Schroth,  advising  him  not  to  inter- 
fere with  such  a  desperate  case,  for  fear  that  the  apparently  unhappy 
final  result  would  militate  against  him.  But  Schroth  asked  of  the 
Duke  three  days  for  consideration,  and  then  said,  with  full  convic- 
tion, to  the  well-meaning  physician:  'The  Duke  will  be  cured.  I 
am  sure  of  success.' 

"The  discoverer  of  this  mode  of  treatment,  to  make  such  a  cure 
possible,  first  found  it  necessary  to  build  up  the  entire  constitution. 
Otherwise  a  continuous  curative  reaction  would  have  been  impossi- 
ble. About  the  middle  of  November,  Schroth  commenced  the  treat- 
ment, and  from  this  time  until  December  30th,  the  Duke  ate  and 
drank  every  day.  Nights,  he  was  wrapped  in  a  peculiar  abdominal 


DEGENERATIONS.  57 

pack,  invented  by  Schroth.  The  diseased  leg  was  gently  rubbed 
mornings  and  evenings,  with  the  moistened  hand,  as  long  as  possible 
on  account  of  pain  excited,  then  soft  linen,  in  the  form  of  straps, 
was  wetted  in  cold  water  and  wrapped  about  it  fourteen  or  sixteen 
thicknesses,  and  allowed  to  remain  twelve  hours,  by  which  time  the 
dressing  had  become  dry.  The  Prince  himself  thus  reports  the  his- 
tory of  the  treatment : 

"'My  diet  was  extremely  simple.  In  the  forenoon  I  ate  nothing, 
as  I  did  not  like  the  stale  bread.  At  noon  I  got  a  piece  of  dry 
boiled  beef,  and  occasionally,  some  dry  rice  or  potatoes  with  the 
same  in  the  afternoon,  at  about  four  o'clock,  and  was  permitted  to 
drink  some  wine,  to  which,  however,  I  could  not  accustom  myself, 
in  spite  of  being  very  thirsty.  Not  until  after  a  fortnight  I  began 
to  get  accustomed  to  get  along  without  water.  The  suqcess  of  this 
treatment,  which  was  just  as  simple  as  ingenious,  was  surprising  in 
the  highest  degree.  On  the  second  day  the  already  cicatricial  por- 
tions of  the  wound  opened  again,  and  a  great  deal  of  pus  was  dis- 
charged; the  existing  severe  pain  diminished,  I  got  easy,  and  the 
fever  disappeared.  At  the  same  time  my  appetite  improved,  and  at 
the  fair  at  Lindeweise,  which  was  just  then  celebrated,  I  ate  as  much 
as  anyone.  On  this  occasion  I  tested  Old  Schroth's  ingenuity.  To 
my  great  satisfaction  he  allowed  me  to  eat  some  beef  soup,  which 
he  had  strictly  forbidden  in  case  of  wounds.  On  the  very  same 
evening,  when  the  bandage  was  removed,  we  noticed  a  very  bad  swell- 
ing about  the  kuee,  just  as  he  had  predicted,  and  Schroth  explained 
to  me  the  effect  of  beef  soup  on  wounds,  as  long  as  the  stomach  can- 
not digest  normally.  In  order  to  have  the  case  tested  further,  he 
encouraged  me  to  drink  some  cold  beer,  on  the  next  afternoon.  I 
drank  about  two  glasses,  and  when  he  bandaged  the  wound  about 
three  hours  afterwards,  it  showed  a  gray-colored,  morbid  pus,  on 
the  lower  part  of  the  wound,  and  on  the  upper,  watery  matter  was  dis- 
charged. The  borders  of  the  wound  were  also  very  red  and  painful. 
This  was  a  clear  proof  that  my  digestion  was  very  poor,  and  that  all 
fluids  went  directly  to  the  wound.  A  general  consumption  would 
have  been  the  inevitable  consequence  of  persisting  in  such  a  course.' 

"  On  December  2d,  the  patient  could  step  on  the  wounded  leg 
for  the  first  time  since  Novara,  and  walk  several  times  up  and  down 
his  room.  The  limb  showed  more  strength,  but  there  was  yet  pain 
in  the  knee  and  articulations  of  the  foot.  At  last,  the  fever  left 
entirely. 

"When  the  healing  process  commenced,  the  regular  treatment  was 
begun.  He  was  now  wrapped  in  large  packs,  but  his  system  was  so 
much  exhausted  that  Schroth  allowed  him  to  continue  his  previous 


58  INTRODUCTION. 

diet.  Not  nntil  the  middle  of  January  was  his  strength  built  up  suf- 
ficiently to  enable  him  to  undergo  the  main  or  regular  treatment, 
and  the  patient  himself  says  the  following  about  it: 

"'The  more  thirsty  I  was,  the  more  pus  was  discharged  from  the 
wound.  This  was  a  dark,  tenacious  liquid,  mixed  with  blood,  and 
of  a  very  bad  odor.  The  more  pus  discharged,  the  stronger  and  more 
movable  became  the  leg.  When,  after  about  three  weeks,  my  tongue 
got  clean,  and  the  discharged  liquid  became  lighter  in  color,  Schroth 
allowed  ree  to  enter  the  so-called  after-cure.  In  a  few  days  the 
suppuration  ceased,  and  in  a  few  days  more  the  wounds  closed  up 
entirely.  During  the  main  cure  I  had  lost  a  great  deal  of  flesh,  but 
now,  when  I  was  filling  up  again,  my  leg  got  very  strong,  and  it  took 
only  a  short  time  to  overcome  the  limping  and  be  again  in  full 
strength  and  health.  At  the  end  of  January  I  made  my  appearance  at 
Grafenberg,  to  show  the  followers  of  Priesnitz'  hydropathic  cure 
the  great  and  wonderful  results  of  S^hroth's  mode  of  treatment.  On 
March  1st  I  considered  myself  as  being  in  normal  health,  and  am 
under  obligation  to  Father  Schroth  for  this  extraordinary  cure  in  the 
short  space  of  sixteen  weeks.' 

"The  Duke,  in  grateful  acknowledgment,  published  the  following 
article,  in  No.  43  of  the  journal  Oesterreichischer  Sctdatenfreund,  Vienna, 
April  23d,  1850: 

" '  To  MY  COMRADES  IN  THE  ARMY  :  The  undersigned  considers  it  his 
duty  to  direct  the  attention  of  his  wounded  comrades  to  a  new  mode 
of  treatment,  which  effects  a  surer  cure  than  all  modes  of  treatment 
practiced  by  physicians.  The  farmer,  Johannes  Schroth,  at  Neider- 
limlewiese,  near  Freiwaldau,  in  Austrian  Silesia,  for  many  ye;irs  has 
treated  fresh  and  old  wounds  by  a  new  and  extraordinary  method, 
and  at  all  times  attains  a  most  successful  result,  but  the  same  is 
very  little  known. 

"  'A  great  many  call  his  cure  "the  stale  bread  cure,"  and  ridicule 
the  same,  because  they  think  he  cures  wounds  with  stale  bread;  but 
this  is  not  the  case.  The  principle  of  Schroth's  cure  is  not  to  allow 
much  fluid  to  go  to  the  wounds,  and  he  effects  it  by  a  strict,  dry  diet. 
He  forbids  his  patients  the  drinking  of  water  entirely,  and  orders 
mainly  stale  bread  and  wine  for  nourishment.  At  the  same  time  he 
applies  local  packs,  which  may  remain  a  longer  or  shorter  time, 
depending  upon  circumstances.  It  cannot  be  said  that  the  cure  is 
easy,  but  it  is  neither  very  hard,  and  not  a  great  sacrifice  for  a  sure 
recovery  of  health. 

"'I  will  cite  some  cases,  beginning  with  my  own.  A  pointed  ball 
had  pierced  my  shin  directly  below  the  knee.  I  had  been  in  bed  for 


DEGENERATIONS.  69 

nine  months,  and  there  was  no  hope  of  a  recovery ;  but  Schroth  cured 
me  in  four  months.  The  pensioned  Colonel  of  Tschebury  had  been 
suffering  since  1809,  from  the  consequences  of  several  wounds.  Dur- 
ing 1849  he  use  I  the  cure  and  got  cured  from  all  his  old  troubles. 
An  old  wound  of  course  needs  a  longer  time  to  get  well  than  a  new 
one,  but  in  the  latter  case  the  success  was  extraordinarily  rapid  and 
brilliant. 

"'Two  cases  more  which  occurred  under  my  own  observation  will 
finish  my  account  of  cures.  A  farmer's  girl  had  her  arm  fractured 
and  the  joint  splintered.  By  the  use  of  packs  and  a  peculiar  diet, 
Schroth  cured  this  case  in  such  a  manner  that  she  could  afterward 
use  her  arm  as  well  as  ever.  An  old,  strong  farmer  cut  his  shin-bone 
with  an  ax,  almost  through,  and  several  tendons  were  severed.  After 
three  weeks'  treatment  he  was  able  to  use  his  leg  ap;ain. 

"'I  shall  be  very  glad  at  any  time  to  give  my  comrades  of  the 
army  details  of  this  treatment,  which  saved  me,  and,  I  hope,  will  do 
a  great  deal  more  for  others. 

WILLIAM,  Duke  of  Wurtemberg. 

"'Vienna,  August.  1850.'" 

It  is  upon  such  principles  as  these  that  Dr.  Weber  depends  for 
the  cure  of  pulmonary  and  other  forms  of  tuberculosis ;  and  that  he 
cures,  I  have  reason  to  know.  Withdrawal  of  water  from  the  system 
increases  the  proportion  of  red  corpuscles  and  other  solid  constitu- 
ents and  improves  the  reparative  power  of  the  circulating  fluids. 
Withdrawal  of  fluids  also  seems  to  cause  rapid  destruction  of 
abnormal  tissues  of  feeble  vitality,  and  they  melt  away  and  are  dis- 
charged. Tubercles  break  down  and  are  cast  off  under  the  new  con- 
ditions, while  the  formation  of  grauulation-tissue  and  other  steps  of 
tubercle  growth  are  arrested,  and  the  evacuated  cavities  are  cicatrized. 

There  are  many  unpleasant  features  connected  with  the  manage- 
ment of  this  mode  of  treatment  of  such  cases,  the  principal  causes  of 
contention  being  the  prejudices  of  both  popular  and  professional 
sentiment  and  education.  The  idea  of  limiting  the  diet  of  a  con- 
sumptive patient,  in  the  light  of  our  present  education,  seems  atro- 
cious; yet  we  might  recollect  that  those  who  are  most  freely  fed  may 
die  sooner  than  those  who  are  not  so  well  favored  (?).  Plenty  of 
ordinary  food  and  drink  seem  to  furnish  the  very  pabulum  required 
for  the  rapid  development  of  the  bacilli  and  production  of  tubercle 
deposit. 

Wine  alleviates  the  thirst  somewhat,  but  not  altogether;  but  here 
it  is  a  medicine.  It  hardens  the  tissues,  and  fortifies  them  against 
the  inroads  of  the  bacilli  Possibly  these  are  starved  out  for  lack  of 
water,  as  vegetable  organisms  require  this  for  their  proper  growth, 
and  animal  tissues  possessing  the  best  absorbing  power,  probably 


60  INTRODUCTION 

and  animal  tissues  possessing  the  best  absorbing  power,  probably 
rob  them  of  the  limited  supply  furnished  by  a  dry  diet  But  these 
are  theories,  though  the  facts  remain. 

The  patient  becomes  fearfully  emaciated  at  first,  and  had  better 
not  be  seen  by  his  friends,  as  they  will  not  now  be  likely  to  add 
encouragement  to  his  resolution  to  persevere.  As  75  per  cent  of 
the  body  is  water,  withdrawal  of  a  large  proportion  of  the  amount 
ordinarily  consumed  must  bring  about  a  remarkable  shrinkage  in  bulk. 
The  patient  soon  becomes  fearfully  weak  and  emaciated,  the  expec- 
toration increases  in  amount,  and  symptoms  are  at  first  most  threat- 
ening. But  after  a  few  weeks  the  amount  of  material  expectorated 
begins  to  grow  markedly  less  in  amount,  and  finally  ceases  altogether, 
though  treatment  must  be  faithfully  continued  until  the  cough  and 
expectoration  have  ceased  entirely.  Then,  even  upon  the  limited 
diet,  the  patient  gradually  regains  digestive  power  and  strength. 

IV.    BACTERIOLOGY. 

BACTERIOLOGY  is  the  science  of  bacteria.  Bacteria,  microorgan- 
isms, or  microbes,  are  minute  vegetable  organisms  representing  the 
lower  forms  of  vegetable  life  and  related  to  the  algae  botanically,  which 
naturally  maintain  a  parasitic  existence  in  human  and  animal  fluids 
and  tissues,  but  many  of  which  may  be  cultivated  artificially  outside 
these  situations.  As  vegetable  organisms,  they  are  peculiar  on 
account  of  the  absence  of  chlorophyl  in  their  composition,  and  in 
their  mode  of  reproduction  by  fission,  and  the  formation  of  spores. 
•  They  normally  exist  in  communities  of  many  different  kinds,  and 
possess  the  power  of  rapid  multiplication,  under  proper  circumstances. 
This  fact  confused  positive  knowledge  of  their  relation  to  disease 
until  bacteriological  research  separated  them  by  cultivation  into  pure 
cultures,  enabling  inocultion  tests  as  to  the  specific  character  of 
many  distinct  forms,  to  be  made  upon  animals. 

When  developed,  a  bacterium  represents  a  cell,  consisting  of  an 
enveloping  membrane  containing  protoplasm.  The  membrane  is  usu- 
ally very  firm  and  adherent,  is  separated  from  the  protoplasm  with 
difficulty,  and  is  also  resistant  to  external  influences. 

TECHNOLOGY. 

A  knowledge  of  the  peculiar  characteristics  of  individual  bacteria 
comes  from  ability  to  isolate  them  by  cultivation.  A  portion  of  dis- 
eased structure  may  contain  numerous  colonies  of  bacteria  in  con- 
fused admixture,  these  differing  materially  in  their  properties  and 
significance.  One  variety  may  be  innocuous,  another  may  exist  there 
accidentally,  while  still  others  may  sustain  a  direct  causal  relation 
to  the  pathological  condition. 


BACTERIOLOGY.  61 

Nutrient  media  are  necessary  for  the  cultivation  of  bacteria  out- 
side of  animal  tissues;  and  of  these  two  classes  are  employed,  viz., 
natural  and  artificial. 

Natural  media  are  those  which  are  employed  in  their  natural  state, 
such  as  pleuritic  fluid,  the  fluid  of  hydrocele,  blood-serum,  potato 
and  other  vegetables,  eggs,  etc. 

Artificial  media  are  prepared  substances,  such  as  bouillon,  gela- 
tine, agar,  and  certain  saline  mixtures,  such  as  Pasteur's,  Cohn's, 
and  other  preparations  classed  as  mineral  media. 

Some  bacteria  thrive  best  on  one  material,  and  others  on  another. 

A  variety  of  media  are  therefore  necessary,  in  order  to  meet  the 
demands  of  different  occasions. 

Sterilization  of  everything  connected  with  the  manipulation  of 
bacteria  is  necessary  in  the  successful  propagation  of  pure  cultures. 
Great  dexterity  is  also  requisite  upon  the  part  of  the  manipulator, 
in  order  that  successful  results  may  be  arrived  at.  A  sterilized 
chamber  for  the  prosecution  of  bacteriological  experiments  is  essen- 
tial, and  ovens  for  the  sterilization  of  everything  connected  with  the 
work  must  be  at  hand,  as  a  few  seconds'  exposure  to  the  air  may 
contaminate  a  pure  culture,  and  thus  destroy  accuracy.  On  this 
account  the  most  expert  operator  may  fail  to  propagate  successfully. 

A  knowledge  of  microscopy  is  also  essential,  and  the  operator  must 
understand  mounting  specimens  and  adjusting  them  upon  the  stage, 
so  as  to  bring  them  into  proper  light  and  focus. 

Staining  of  specimens  is  also  an  important  matter,  and  this  com- 
prehends considerable  skill  and  experience. 

The  technique  of  obtaining  a  pure  culture  from  a  mixture  of  a  vari- 
ety of  germs  may  be  briefly  summarized  as  follows: 

Sterilized  media  are  inoculated  with  a  sterilized  platinum  needle 
from  the  pathological  specimen  to  be  investigated,  in  successive 
series,  upon  the  principle  of  dilution  observed  in  preparing  drug- 
attenuations.  For  example,  after  one  inoculation  has  been  made  the 
second  is  carried  on  from  this,  the  third  from  the  second,  and  so  on. 
Usually  the  third  inoculation  so  reduces  the  number  of  bacteria  that 
they  may  be  singled  out  by  spreading  the  medium  in  a  thin  layer 
upon  a  sterilized  plate,  each  one  then  breeding  a  separate  colony. 
Each  of  these  may  now  be  transferred  to  a  separate  culture-mediuhi, 
and  if  it  contain  only  the  one  kind  of  microbes,  upon  growing, 
it  constitutes  a  pure  culture. 

Guinea-pigs,  mice,  and  other  lower  animals  may  be  inoculated 
from  these  cultures,  and  the  effects  observed.  Some  may  prove 
wholly  inocuous,  others  producing  variable  symptoms.  When  one 
of  the  cultures  constantly  proves  toxic,  its  effects  are  more  carefully 


62  INTRODUCTION. 

observed,  and  in  this  manner  the  specific  causes  of  various  infectious 
diseases  are  determined.  However,  there  is  not  always  a  certainty 
as  to  the  specific  microbe  of  a  disease,  as  bacteriologists  are  frequently 
compelled  to  abandon  positions  which  have  been  taken  with  much 
positiveness.  The  toxines  generated  by  bacteria  seem  to  vary  in 
their  poisonous  influence  in  different  individuals,  depending  perhaps 
upon  constitutional  susceptibility  or  temporary  predisposition,  owing 
to  constitutional  depravity,  and  confusion  arises,  where  it  might  seem 
that  like  causes  ought  always  to  be  followed  by  like  results.  To 
illustrate  the  meaning  here  it  may  be  remarked  that  the  Klebs- 
LofHer  bacillus,  which  was  but  recently  regarded  as  the  specific 
microorganism  of  diphtheria — declared  so  by  both  investigators  after 
careful  and  painstaking  investigation — seems  innocuous  in  some 
instances,  and  has  been  found  in  the  buccal  and  nasal  cavities  of 
perfectly  healthy  persons.  With  all  the  positiveness  of  bacterial 
research,  then,  there  seems  to  be  much  uncertainty,  after  all. 

A  large  majority  of  bacterial  forms  grow  freely  in  gelatine  and 
agar,  though  some,  such  as  the  tubercle  bacillus,  gonococcus,  and 
others,  require  special  media.  Others,  such,  for  example,  as  the 
spirochsBte  of  Obermaier,  cannot  be  cultivated  in  any  known  medium. 

STAINING  AND  PREPARING. 

THE  peculiar  resistant  qualities  of  bacteria  enable  them  to  retain 
coloring  material  when  surrounding  tissues  or  media  yield  to  bleach- 
ing influences.  Aniline  colors  are  chiefly  employed  for  staining, 
these  being  retained  by  the  microbes,  while  they  are  removed  from 
surrounding  parts  by  bleaching,  with  different  processes.  Thus  the 
bacteria  are  left  highly  colored,  while  the  field  in  which  they  lie  is 
approximately  achromatic,  rendering  them  prominent  to  vision  under 
proper  magnifying  power.  Basic  dyes  possess  special  value  for  pen- 
etrating the  nuclei  of  cells  and  bacteria,  and  when  such  colored 
specimens  are  heated  in  acetic  acid  the  nuclei  are  dissolved,  diffusing 
the  coloring  material  through  the  protoplasm  generally,  rendering 
the  complete  organism  distinct.  The  basic  dyes  most  in  use  are 
methyl  blue,  methyl  violet,  gentian  violet,  dahlia,  basic  fuchsine, 
Bismarck  brown,  etc.  Some  bacteria  cannot  be  penetrated  with 
simple  solutions  of  basic  dyes,  and  more  complex  preparations  are 
required. 

L&filer's  sdution  may  be  resorted  to  here.  A  compound  of  30 
parts  of  a  concentrated  alcoholic  solution  of  methyl  blue,  and  100 
parts  of  a  1-1000  solution  of  caustic  potash  in  water  is  first  used. 
After  the  preparations  remain  in  this  for  a  few  minutes,  they  should 
be  treated  with  a  \%  solution  of  acetic  acid,  then  washed  with  abso- 
lute alcohol,  and  cleared  with  cedar  oil. 


BACTEKIOLOGY.  63 

Gram's  method  is  a  favorite  one  with  bacteriologists.  In  this, 
the  specimens  must  be  put  to  macerate  in  absolute  alcohol,  before 
the  staining  process.  After  removal  from  this,  the  prepared  cover- 
glasses  are  allowed  to  float,  prepared  side  down,  upon  a  mixture 
composed  of  water  solution  of  aniline  oil  100  parts,  to  saturated 
solution  of  gentian  violet  5  parts,  for  a  few  minutes.  From  here 
they  are  transferred  to  an  iodo-iodide  of  potash  solution,  and  allowed 
to  remain  for  one  minute,  when  they  are  washed  with  absolute  alco- 
hol from  one  to  three  minutes,  until  they  become  free  from  color  to 
the  naked  eye.  They  are  then  cleaned  up  in  oil  of  cloves,  and 
mounted  in  Canada  balsam  or  glycerine-jelly. 

This  method  stains  the  bacillus  tuberculosis;  bacillus  anthracis; 
bacillus  leprae;  diplococcus  pneumoniae;  pneumococcus  Friedlander; 
streptococcus  erysipelatis;  actinomyces;  and  all  pyogenic  bacteria. 

It  does  not  stain  the  bacillus  of  glanders  (bacillus  mallei); 
bacillus  typhosus  (bacillus  of  Eberth);  diplococcus  intercellularis 
meniugitis;  gonococcus;  spirillum  choleras  asiaticaa  (comma  bacil- 
lus); or  spirochaete  Obermaieri  (relapsing  fever). 

Of  these,  Loffler's  solution  stains  gonococcus,  diplococcus  inter- 
cellularis, and  bacillus  typhosus.  Water  solutions  of  dyes  stain 
bacillus  mallei,  spirillum  choleraa,  and  spirochsete  Obermaieri,  these 
being  afterward  brought  out  with  1%  solution  of  acetic  acid. 

Preparations  may  be  double-stained,  so  that  the  field  and  bacteria 
present  contrast  colors,  the  bacteria  presenting  a  deep  blue  tint, 
while  the  ground  or  field  is  carmine,  a  strong  and  attractive  contrast 
thus  being  made,  and  the  bacteria  being  brought  out  more  clearly. 

The  tubercle  bacillus  is  so  important  that  special  attention  to  its 
staining  will  be  proper.  In  common  with  the  bacillus  of  leprosy  it 
differs  from  other  bacteria  in  resisting  the  bleaching  power  of  strong 
mineral  acids.  Cover-glass  preparations  of  sputum,  blood,  tubercle, 
pus,  etc.,  containing  this  microbe  should  be  first  treated  with  a 
solution  composed  of  100  parts  of  aniline  water,  11  parts  of  an  alco- 
holic solution  of  fuchsine,  methylene  blue,  or  methyl  violet,  and  10 
parts  of  absolute  alcohol  (Erlich's  solution).  At  ordinary  tempera- 
tures the  specimens  should  be  allowed  to  remain  in  this  for  twenty- 
four  hours.  If  the  solution  containing  the  specimens  is  heated, 
a  few  minutes  will  suffice,  this  being  termed  the  "rapid  process." 
The  cover-glass  preparations  should  now  be  removed  and  passed  over 
a  gas-jet  three  or  four  times,  until  steam  begins  to  rise.  After  this 
they  should  be  washed  in  a  solution  consisting  of  nitric  acid  one 
-part,  to  water  two  or  three  parts.  After  nearly  decolorized,  wash  in 
plenty  of  water  or  alcohol.  Sections  should  be  treated  with  alcohol, 
cleared  with  oil  of  cloves,  and  preserved  in  balsam. 


r,4  INTRODUCTION. 

But  this  process  will  also  develop  the  bacillus  of  leprosy,  aiid 
the  following  method  will  be  useful  to  distinguish  between  these  twc 
forms  of  bacteria.  Fill  a  watch-glass  with  water,  and  add  from  four 
to  six  drops  of  a  saturated  alcoholic  solution  of  fuchsine.  In  this 
place  the  cover-glass  preparation  for  six  or  eight  minutes,  and  after- 
ward treat  with  1-10%  nitric  acid  for  twenty  seconds,  afterward 
washing  in  distilled  water  and  treating  with  aqueous  solution  of 
methylene  blue.  After  this  clear  with  oil  of  cloves.  This  removes 
coloring  from  the  tubercle  bacilli,  leaving  only  the  bacilli  of  leprosy. 
If  nothing  can  now  be  seen,  the  microbes  before  observed  were  evi- 
dently those  of  tuberculosis.  If  sections  are  to  be  treated,  allow  them 
to  remain  in  Erlich's  solution  for  two  or  three  minutes,  after  which 
pass  through  the  nitric  acid  solution  for  half  a  minute,  then  stain 
with  water  solution  of  methyl  blue.  Only  the  bacilli  will  be  stained 
by  this  process. 

BIOLOGY. 

EARLY  investigators  in  the  domain  of  bacteria  inclined  toward 
the  belief  that  they  all  sprung  from  a  common  source,  and  that  the 
different  forms  represented  various  stages  of  development,  or  the 
influences  of  varying  environment.  But,  while  one  species  may  be 
represented  by  different  forms  during  development,  the  mature  form 
of  an  individual  species  does  not  vary,  and  its  individual  char- 
acteristics and  properties  are  always  the  same,  under  the  same 
circumstances. 


**» 

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Ua  tt     '  — V^ 

FOBMS  OF  BACTERIA. 

Experiments  in  propagation  have  demonstrated  that  more  than 
thirty  generations  of  pus-microbes  and  other  kinds  may  be  cultivated 
without  change  of  form  or  property.  They  are  as  distinctly  sep- 
arate species  at  the  end  of  this  time  as  in  the  beginning. 

Three  distinct  forms  of  pathogenic  bacteria  have  been  discovered 
and  described,  namely,  (1)  the  ball  or  berry  (coccus),  (2)  the  rod 
(bacillus),  and  (3)  the  corkscrew  (spirillum  or  spirochcete). 

In  some  instances  there  may  be  a  near  approach  in  the  resem- 
blance between  two  individuals  belonging  to  different  classes.  For 


BACTERIOLOGY.  65 

instance,  an  oblong  coccus  may  resemble  a  short  bacillus,  a  double 
coccus  a  short  bacillus  with  club-shaped  ends,  etc. 

When  cocci  are  arranged  in  pairs,  they  are  called  diplococci. 
When  in  fours,  and  in  the  form  of  a  square,  rnicrococcus  tetragones. 
When  in  the  form  of  a  cube,  sarcina.  When  arranged  in  the  shape  of 
a  bunch  of  grapes,  staphylococci.  When  they  are  arranged  in  chains, 
streptococci.  An  irregular  bunch,  held  together  in  a  mass  by  a  vis- 
cid fluid,  is  termed  a  zooglcea. 

WTheu  circumstances  are  favorable  to  their  development,  the 
reproduction  of  bacteria  occurs  with  great  rapidity.  In  some  forms 
multiplication  is  brought  about  by  fission  or  splitting  of  the  bacte- 
rium into  halves.  In  others,  the  multiplication  results  from  the 
development  of  spores,  similar  to  the  seed  formation  of  flowering 
plants.  The  cocci  multiply  by  fission.  A  cell  elongates  and  becomes 
constricted  in  the  middle.  As  the  constricting  process  continues, 
the  bacterium  separates  into  two  equal  parts,  each  of  which  soon 
attains  the  size  of  the  parent  cell.  If  the  cells  remain  in  contact  and 
multiplication  continues  longitudinally,  a  chain  or  streptococcus  is 
formed.  Rod  bacteria  which  multiply  by  fission  separate  in  the  mid- 
dle and  each  half  grows  to  the  size  of  the  parent,  when  separation 
occurs  in  each  half,  as  in  the  parent  cell.  Bacilli  usually  multiply 
from  spores.  When  these  develop  in  a  bacillus,  darkened  spots 
first  appear  at  equidistant  points,  which  soon  (within  twenty  hours) 
develop  into  pearly,  opaque  segments.  These  then  part,  and  each 
develops  into  a  separate  bacterium.  Spores  are  usually  more  resist- 
ing to  destructive  influence  than  bacteria,  though  a  heat  of  212°  F. 
destroys  them. 

The  nutrition  of  bacteria  demands  oxygen,  nitrogen,  carbon, 
water,  and  a  limited  amount  of  mineral  salts.  Water  is  indispensa- 
ble to  their  growth,  and  prolonged  desiccation  is  fatal  to  many,  though 
others  may  exist  for  a  long  time  in  a  dormant  state  when  desiccated, 
to  renew  activity  when  moisture  is  supplied.  Oxygen  is  indispensa- 
ble, though  some  grow  in  open  air,  while  others  cannot  be  cultivated 
except  in  media  in  which  they  can  grow  beneath  the  surface.  Bacte- 
ria which  grow  only  in  the  open  air  are  termed  aerobii;  those  which 
only  grow  away  from  the  opeu  air,  anaerobii;  others,  which  can 
grow  in  either  situation,  are  termed  anaerobii  by  election.  Bacteria 
obtain  their  carbon  and  nitrogen  principally  from  the  media  in 
which  they  grow.  Their  growth  brings  about  certain  changes  in  the 
media  which  determine  their  character,  in  certain  directions.  For 
example,  certain  kinds  decompose  their  media  and  produce  color 
(chromogenic  bacteria).  Others  give  rise  to  ferments  (zymogenio 
bacteria ).  Still  others,  and  the  important  class  to  physicians,  origi- 


66  INTRODUCTION. 

nate  various  toxic  conditions  (pathogenic  or  disease-producing 
bacteria). 

Many  bacteria  possess  the  power  of  spontaneous  motion,  from 
conditions  of  their  nutrition.  The  motion  may  be  directly  due  to 
cilia,  with  which  some  forms  are  supplied,  or,  in  other  cases,  to 
contraction  of  the  protoplasm  In  other  instances  both  these  agen- 
cies may  be  concerned. 

Certain  conditions  or  provisions  are  essential  n  determinin  :  the 
identity  of  pathogenic  bacteria.  Thev  must  be  found  in  the  bodies  of 
animals  or  human  subjects  suffering  with  or  dead  from  disease. 
They  should  be  cultivated  from  such  sources,  when  possible,  and  a 
pure  culture  of  them  should  produce  the  same  disease  when  inocu- 
lated into  animals.  Such  animals,  when  diseased,  should  contain  in 
their  blood  and  tissues  the  identical  bacteria  found  in  the  tissues  or 
fluids  of  the  affected  individual  in  the  beginning. 

Bacteria  cause  disease  in  different  ways.  Some  kinds  (pyogenic 
bacteria)  attack  the  leucocytes  and  embryonal  cells  and  convert  them 
into  pus-corpuscles.  Others  produce  hyperplasia  and  the  develop- 
ment of  new  growth,  as  in  the  generation  of  tubercle.  Still  others 
generate  toxines,  which  produce  constitutional  diseases,  such  as  the 
infectious  fevers. 

Some  infectious  diseases  have  not  yet  been  demonstrated  to  be 
the  results  of  specific  germs,  these  probably  existing,  but  having  thus 
far  escaped  the  scrutiny  of  bacteriologists.  Germs  have  been  dis- 
covered and  declared  the  causes  of  disease,  and  afterward  demon- 
strated to  be  harmless  saprophytes.  The  field  of  bacteriology  is  yet 
full  of  speculation  aud  uncertainties.  Much  remains  to  be  cleared 
up,  and  doubtless  much  has  been  accepted  as  true  which  later 
research  will  determine  as  unfounded. 

A  few  bacteria  have  been  pretty  well  located  and  described. 
Others  are  yet  subjects  of  speculation,  investigation,  and  debate. 
Those  which  are  generally  accepted  as  specific  causes  of  disease  will 
be  briefly  described  in  the  following  order : 

PATHOGENIC   COCCI. 

Diplococcus  Intercellularis  Meningitis. — This  is  found  in  the  exuda- 
tion of  cerebro-spinal  meningitis.  The  cocci  occur  in  pairs,  united. 

Diplococcus  Pneumonice  Lanceolatus. — Occurs  in  the  exudation  of 
croupous  pneumonia.  Cocci  united  in  twos.  Under  cultivation, 
loses  its  capsule. 

Gonococcus. — Occurs  in  gonorrhceal  pus.  The  cocci  occur  in  twos, 
similar  to  the  arrangement  of  coffee-grains. 

Staphylococcus  Pyogencs  Aureus. — Foundin  yellow  pus.  The  cells 
are  grouped  in  bunches,  and  are  of  a  yellow  gold  color. 


BACTERIOLOGY.  67 

Stapliylococcus  Pyogenes  Albus. — Found  in  pus,  similar  to  preced- 
ing, except  that  the  color  of  the  cultures  is  white  instead  of  yellow. 

Stapliylococcus  Pyogenes  Citrus. — Also  found  in  pus.  Kesembles 
other  pus-microbes,  except  that  the  cultures  are  lemon-colored. 

Streptococcus  Pyogenes. — Occurs  in  the  pus  of  phlegmons,  in  the 
shape  of  chains  of  cocci. 

Streptococcus  Erys'ipelatis. — Found  in  the  lymph-spaces  of  erysip- 
elatous  parts.  It  is  probably  identical  with  streptococcus  pyog- 
enes,  though  found  under  different  circumstances. 

PATHOGENIC   BACILLI. 

Bacillus  Anthracis. — The  bacillus  of  anthrax,  found  in  the  lymph 
and  blood  of  animals  suffering  from  splenic  fever.  It  occurs  in 
single  rods  or  long  chains,  when  cultivated. 

Bacillus  (Edematis  Malignce. — The  bacillus  of  malignant  oedema. 
Found  in  human  subjects  and  animals  suffering  with  this  disease. 
Grows  under  gelatine  (anaerobic),  giving  rise  to  gas  bubbles. 

Bacillus  Leprce. — The  microbe  of  leprosy,  found  in  leprous 
tubercle.  It  resembles  the  bacillus  of  tuberculosis.  Grows  in 
blood-serum. 

Bacillus  MaUeL — A  short,  slender  rod,  resembling  the  bacillus  of 
tubercle,  found  in  the  secretions  and  tissues  of  subjects  suffering 
with  glanders.  Grows  on  blood-serum  and  potato. 

Bacillus  Pneumonia. — Short  rod.  single  or  in  chains,  found  in  the 
exudation  of  croupous  pneumonia.  It  is  covered  with  a  capsule  in 
pneumonia,  but  the  capsule  is  absent  in  cultures.  It  grows  on 
gelatine. 

Bacillus  Bhinosclerma. — Found  in  the  tubercles  of  rhinosclerma. 
Resembles  the  diplococcus  pneumonise  in  form  and  cultures. 

Bacillus  of  Syphilis. — A  short  rod  found  in  the  lesions  of  syphilis. 
It  has  not  been  cultivated. 

BaciUus  Typhosus. — The  bacillus  of  typhoid  fever.  A  short  rod 
with  rounded  ends,  found  in  the  evacuations,  and  also  in  the 
mesenteric  glands  and  spleen  of  subjects  affected  with  the  disease. 

PATHOGENIC   8PIBILLI. 

Spirillum  Choleras  Asiaticce. — Curved  rods,  resembling  a  comma  in 
shape,  sometimes  curved  in  the  shape  of  a  letter  S,  and  sometims  of 
corkscrew  form.  Found  in  the  evacuations  of  cholera  Grows  in 
gelatine. 

Spirochcete  Obermaieri. — The  spirillum  of  relapsing  fever.  It  has 
never  been  cultivated,  but  has  been  inoculated,  and  has  reproduced 
the  disease  in  healthy  animals  and  men. 


68  INTRODUCTION. 

PATHOGENIC  PUNQL 

Actinomyces. — The  fungus  ound  in  the  tumors  of  actinomycosis. 
A  club-shaped  fuugus,  which  grows  in  the  form  of  radii.  Has  teen 
cultivated  on  agar,  and  grows  in  small  grayi>h  dots. 

Achorion  Schdnleinii. — The  fuugus  found  in  patches  of  favus. 
When  cultivated  upon  agar,  it  grows  in  patches  presenting  the 
characteristic  color  of  this  aff  ction. 

But  the  science  of  bacteriology  does  not  include  all  the  micro- 
organisms of  disease.  Bacteria  are  vegetable  organisms,  while  there 
are  numerous  instances  in  which  disease  is  caused  by  the  presence  of 
animalcules  in  the  body.  The  plasmodium  of  malaria  is  an  example 
of  this  kind,  and  the  filaria  sanguinis  hominis  another,  these  crea- 
tures existing  in  the  blood,  while  the  trichina  spiralis,  echinococcus, 
germ  of  the  tapeworm,  etc.,  are  embedded  in  the  solid  tissues. 
Due  notice  will  be  given  these  parasites  under  the  diseases  in  which 
they  occur. 


SECTION    II, 

SPECIFIC     INFECTIOUS     DISEASES. 


I.    TYPHOID  FEVER. 

Synonyms. — Enteric  Fever;  Typhus  Abdominalis. 

Definition. — An  acute  infectious  disease  excited  by  a  specific 
bacillus,  and  marked  by  inflammation  of  Peyer's  glands ;  clinically 
characterized  by  fever  of  gradual  development,  headache,  delirium, 
stupor,  abdominal  distention,  diarrhcea,  splenic  engorgement,  and  an 
abdominal  rash. 

Historical  Note. — Prior  to  1813,  typhoid  fever  was  not  dis- 
tinguished from  other  forms  of  protracted  pyrexial  disease.  In 
1813,  Paul  Bretonneau,  of  Tours,  described  "dothienenterite"  as  a 
distinct  disease,  and  contemporary  writers  described  "entero-mesen- 
teric  fever."  The  views  of  Bretonneau  were  disseminated  by  his 
pupils,  especially  by  Trousseau  and  Velpeau,  until  the  profession  of 
Paris  accepted  them.  In  1829,  Louis'  work  was  published,  contain- 
ing a  description  of  typhoid  fever  for  the  first  time  under  that  name 
in  a  recognized  text-book.  The  students  of  Louis  included  members 
of  various  foreign  nations,  among  whom  were  Americans,  Gerhard,  of 
Philadelphia,  soon  publishing,  in  the  American  Journal  of  Medical 
Sciences,  the  first  full  and  accurate  account  of  the  disease  ever  writ- 
ten in  any  language.  James  Jackson,  Jr.,  of  Boston,  another  pupil  of 
Louis,  returned  from  Paris  in  1833,  and  soon  proved,  in  his  father's 
hospital  wards,  the  identity  of  the  then  so-called  typhus  fever  of  this 
country  with  typhoid.  His  death  occurred  soon  afterwards,  but  in 
1838  and  1839,  James  Jackson,  Sr.,  and  Enoch  Hale  prepared  mem- 
oirs which  were  published  by  the  Massachusetts  General  Hospital, 
fully  describing  the  difference  between  typhus  and  typhoid  fever, 
their  views  being  generally  accepted  by  American  physicians,  though 
it  was  several  years  before  the  mass  of  the  profession  in  Europe 
admitted  the  distinction  between  these  two  forms  of  febrile  disease. 
It  was  not  until  1850  that  all  points  of  dispute  were  finally  settled. 

Etiologj^. — It  is  now  generally  conceded  that  typhoid  fever  is 
the  result  of  an  infection  of  the  system  of  the  affected  individual 
with  a  specific  germ  (the  bacillus  of  Eberth).  This  is  found  most 
constantly  in  the  intestinal  discharges  of  the  sufferer,  and,  as  it 
retains  its  vitality  for  a  long  time,  it  may  finally  drift  into  wells,  res- 
ervoirs, or  springs,  thus  contaminating  drinking  water,  the  infection 
entering  by  way  of  the  alimentary  canal.  Even  without  previous 


70  SPECIFIC  INFECTIOUS  DISEASES. 

history  of  typhoid  infection,  the  use  of  potable  water  from  wells  or 
springs  located  in  the  neighborhood  of  privies,  sewers,  or  barn-yards 
is  hazardous,  as  fecal  material  seems  to  possess  the  property  of  pre- 
serving the  typhoid  bacillus  for  years,  if  it  be  not  a  medium  for  the 
germ  from  some  unknown  source  outside  the  human  body.  After 
the  historical  flood  which  occurred  in  Western  Pennsylvania,  in 
1889,  a  widespread  epidemic  of  typhoid  fever  occurre  1  in  the  rural 
districts,  where  it  had  formerly  been  unknown  for  a  long  time, 
and  the  disease  was  traced  to  infected  wells  in  most  instm 
where  it  seemed  probable,  from  their  location,  that  they  had  received 
washings  from  n  ighboring  privies.  But  the  recent  fecal  material 
of  typhoid-fever  patieii  s  is  less  virulent,  though  doubtless  it  is  fre- 
quently a  source  of  contamination  among  nurs3S  and  those  who  wash 
the  clothing.  In  large  towns  and  cities,  where  milk  is  distributed 
from  common  supplies  and  transported  from  rural  districts  where 
contaminated  water  has  been  used  to  rinse  the  cans,  without  scald- 
ing, and  to  increase  the  bulk  of  the  article,  the  cause  of  epidemics 
of  this  disease  is  readily  accounted  for,  provided  the  water  supply 
of  the  hydrants  has  not  been  defiled.  Doubtless  the  bacilli  may 
sometimes  enter  the  circulation  through  the  lungs,  in  the  condition 
of  a  dry  powder,  floating  in  the  atmosphere. 

Certain  predisposing  causes  are  believed  to  operate  in  encour- 
aging the  spread  ot  epidemics,  such,  for  example,  as  the  autumn 
season,  early  life,  etc.  The  greater  prevalence  of  typhoid  fever  in 
the  autumn  is  probably  due  to  the  fact  that  greater  liability  to  con- 
tamination from  drinking  water  and  floating  germs  in  the  atmosphere 
then  prevails.  After  a  protracted  drought,  the  ground  water  is  low, 
and  springs  and  other  water  sources  drain  contaminated  foci  closely, 
thus  being  more  likely  to  be  charged  with  the  specific  poison.  The 
same  atmospheric  condition  may  result  in  the  presence  of  floating 
germs  in  the  air,  which  may  fall  into  drinking  water,  or  enter  the 
system  through  the  organs  of  respiration.  Youth  and  early  adult 
life  is  the  period  of  greatest  susceptibility,  the  majority  of  cases 
occurring  between  the  ages  of  fifteen  and  twenty-five.  It  is  pro- 
gressively infrequent  alter  thirty-five,  though  it  may  occur  at  any 
period,  the  foetus  becoming  infected  through  the  maternal  circula- 
tion during  late  months  of  pregnancy.  Not  all  who  are  exposed  to 
the  contagion  suffer  from  it,  as  all  are  not  susceptible,  and  some 
who  are  affected  do  not  suffer  severely,  perambulating  cases  being 
frequently  observed.  It  occurs  both  epidemically  and  endemically, 
being  endemic  in  most  large  cities,  in  which  case  there  is  great  dif- 
ficulty in  tracing  the  infection  to  its  source. 

One  attack  usually  confers  immunity  against  subsequent  exposure. 


TYPHOID  FEVEK. 


71 


The  bacillus  of  typhoid  fever  is  a  short,  thick,  motile  bacterium 
with  rounded  ends,  in  one  and  sometimes  both  of  which  an  opaque 
glistening  spot  is  observed,  supposed  by  some  to  represent  a  spore, 
it  being  noticed  most  frequently  in  cultures.  These  bacilli  may  be 
preserved  for  an  indefinite  time  in  water,  and  here  they  probably 
slowly  multiply.  A  heat  of  140°  F.  destroys,  though  extreme  cold 
does  not  injure  them,  congealment  in  ice  producing  no  apparent  inju- 
rious effect.  They  multiply  rapidly  in  milk,  and  cultures  grow  in 
various  other  culture-media,  the  growth  being  invisible  on  potato. 
Repeated  trials  of  inoculation  upon  animals  have  failed  to  produce 
the  disease,  though  this  has  been  explained  by  the  hypothesis  that 
animals  are  not  susceptible. 


Pathology. — It  is  highly  probable  that  the  constitutional  dis- 
turbances arise  from  toxines  generated  by  the  bacilli.  Brieger  has 
described  a  typhotoxine,  and  Frankel  a  toxalbumin,  though  knowl- 
edge of  these  poisons  is  not  yet  very  complete.  The  intestinal 
lesions  are  probably  due  to  the  conjoined  local  influence  of  the 
bacilli  and  their  toxines.  To  these  influences  may  be  added  septic 
elements  absorbed  from  the  local  inflammatory  and  necrotic  areas. 

The  characteristic  anatomical  lesions  of  typhoid  fever  are  found 
in  the  alimentary  canal,  though  it  is  important  to  recollect  that 
the  granular  degeneration  (cloudy  swelling)  of  tissue,  common  to  all 
protracted  fevers,  is  marked  in  this  disease,  involving  the  muscular 
structure  of  the  heart,  this  suggesting  great  caution  during  convales- 
cence, lest  the  patient  overtax  his  strength.  According  to  Ziegler, 
the  morbid  changes  in  typhoid  appear  chiefly  in  the  lower  part 
of  the  ileum  and  the  upper  part  of  the  colon ;  they  are  seldom  met 
with  much  higher  or  lower  in  the  intestine.  The  changes  consist 
essentially  of  a  necrotic  inflammatory  infiltration  of  the  follicular 
structures  and  the  parts  around  them,  accompanied  by  a  catarrhal 
inflammation  of  the  rest  of  the  mucous  membrane. 


72  SPECIFIC  INFECTIOUS  DISEASES. 

"In  the  first  few  days  of  the  attack  the  mucous  membrane  of  the 
lower  part  of  the  ileum  and  its  agminated  glands  of  Peyer's  patches 
are  intensely  congested  and  uniformly  swollen.  Soon  the  swelling 
of  the  patches  becomes  more  marked,  raised  and  winding  ridges  not 
unlike  the  cerebral  convolutions  in  miniature  appearing  on  their 
surface.  The  swelling  extends  more  or  less  quickly  over  the  whole 
of  each  patch,  so  that  it  has  iu  general  the  look  of  a  bed  or 
garden  plot  projecting  above  the  general  surface.  When  the  swell- 
ing is  at  its  height,  the  ridges  are  generally  leveled  up,  as  it  were, 
and  are  no  more  distinguishable.  The  surface  of  the  patch  is  then 
smooth,  or  pitted  minute  depressions  correspond  to  the  sites  of  the 
individual  follicles.  The  solitary  follicles  form  rounded  nodules  by 
virtue  of  the  same  process. 

"When  this  stage  (of  swelling)  is  complete,  the  patches  and  fol- 
licles, which  at  first  were  bright  red  in  color,  become  pale  and 
creamy  white. 

"The  swelling  of  the  patches  and  follicles  is  chiefly  due  to  the 
extreme  cellular  infiltration  of  the  mucosa  and  submucosa. 

"The  number  of  swollen  patches  varies  much.  Often  but  a 
small  number  or  even  a  single  one  is  markedly  affected ;  while  in 
other  cases  the  affection  extends  upwards  to  the  jejunum  or  down- 
wards to  the  anus. 


TYPHOID    ULCERS    IN  THE 
CICATRICES  THi  -RESULT  OTTYHOIO 

"In  the  second  week  of  the  disease,  partial  disintegration  and 
necrosis  of  the  swollen  patches  usually  sets  in.  The  disintegration 
attacks  the  whole  of  the  central  part  of  the  patch,  or  two  or  more 
parts  of  it  simultaneously.  The  surface  quickly  assumes  a  frayed  or 


TYPHOID  FEVER.  73 

ragged  appearance,  and  becomes  yellow  or  brown  from  the  action  of 
the  bile.  Gradually  the  disintegrated  tissue  or  slough  becomes 
loosened  at  its  base  and  edges  from  the  surviving  structures,  and 
ID  a  few  days  is  cast  off.  After  the  separation  of  the  sloughs,  an 
erosiou  or  typhoid  ulcer  is  left,  the  floor  of  which  generally  looks 
smooth  and  clean.  The  borders  of  the  ulcer  at  this  stage  are  still 
swollen  and  infiltrated. 

"The  ulcers  usually  remain  coextensive  with  or  very  slightly 
overpass  the  area  of  the  infiltrated  patches  and  follicles ;  they  rarely 
invade  the  tissues  beyond.  Cases  however  occur  in  which,  especi- 
ally around  the  ileo-caecal  valve,  extensive  tracts  of  mucous  mem- 
brane are  attacked  and  disintegrated  by  the  advance  of  the  ulcerative 
process.  In  the  vertical  direction  it  seldom  goes  beyond  the  mucosa 
and  sub  mucosa.  It  is  only  when  the  infiltration  of  the  muscular 
coat  has  been  extreme  that  they  too  break  down  and  ulcerate.  In 
exceptionally  severe  inflammation  the  serous  coat  also  may  be 
attacked,  but  never  to  the  same  extent  as  the  overlying  layers;  per- 
foration and  fatal  peritonitis  may  occur  in  such  a  case. 

"The  processes  of  absorption  and  repair  begin  at  various  stages 
of  the  disease.  If  no  necrosis  takes  place,  the  swelling  of  the 
patches  goes  down  as  the  infiltrated  material  is  absorbed;  the  patches 
thereupon  become  less  stiffly  turgid,  and  once  more  hyperaemic. 
Bed  corpuscles  escape  from  the  damaged  vessels,  and  the  tissue  takes 
on  a  red  or  blood-stained  tint  which  presently  turns  to  a  slaty 
gray.  The  infiltrated  borders  of  the  ulcers  become  reduced  and 
softened,  and  hypersernic  by  the  same  steps.  Often  enough  consid- 
able  hemorrhage  ensues,  leading  not  only  to  hemorrhagic  infiltration 
of  the  tissue  but  to  actual  escape  of  blood  into  the  intestinal  canal. 
As  the  healing  process  goes  on,  the  softened  and  overhanging  bor- 
ders of  the  ulcer  become  adherent  to  the  floor;  the  latter  is  gradu- 
ally covered  over  with  delicate  granulations,  and  soon  receives  an 
investment  of  epithelial  cells." 

Fortunately,  the  site  of  a  typhoid  ulcer  heals  without  contrac- 
tion, and  intestinal  stricture  does  not  follow  the  extensive  ulceration 
that  so  frequently  attends  ordinary  suppurative  processes.  A 
smooth,  shallow  depression  remains  for  a  long  time,  presenting  a 
slaty-gray  color,  and  devoid  of  glands  and  follicles. 

The  meseuteric  glands  are  more  or  less  involved,  those  whose 
absorbents  correspond  to  the  portions  of  the  intestine  principally 
affected  showing  the  most  important  changes.  They  become  enlarged 
at  the  outset,  and  after  the  tenth  or  fourteenth  day  begin  to  softeu, 
their  contents  becoming  friable  at  first,  and  later  degenerating  into 
a  pus-like  fluid,  mixed  with  sloughs.  Finally,  the  glands  become 


74  SPECIFIC  INFECTIOUS  DISEASES. 

tough,  contracted  and  shriveled.  Daring  the  period  of  softening 
they  may  burst  iuto  the  peritoneum. 

The  spleen  becomes  congested  aud  softened,  its  cells  undergoing 
granular  degeneration.  The  liver  partakes  of  similar  characteris- 
tics, and  the  gall-bladder  may  be  the  seat  of  catarrhal  or  diphthe- 
ritic inflammation.  During  the  late  stage  of  the  disease  the  bile  may 
be  watery  in  consistence,  colorless,  and  acid  in  reaction.  Peritonitis 
may  occur  from  extension  of  the  intestinal  irritation;  from  intestinal 
perforation;  from  rupture  of  mesenteric  glands,  or  spleen;  or  from 
perforation  of  an  ulcer  in  the  gall-bladder.  The  kidneys  may 
become  congested,  and  the  tubules  choked  up  with  detached  epi- 
thelium, owing  to  granular  degeneration  of  the  cellular  elements. 
The  congestion  may  also  extend  to  the  mucous  coat  of  the  blad- 
der. Pulmonary  congestion  is  almost  always  found  among  the 
post-mortem  evidences  of  the  disease.  The  blood  is  tlark  and  fluid, 
and  the  white  corpuscles  are  increased  in  number.  Disintegration 
of  the  red  corpuscles  is  also  noticeable  at  times.  No  particular 
changes  are  observable  in  the  nervous  system,  though  there  may  be 
an  excess  of  serum  in  connection  with  the  brain  and  its  membranes. 

Symptoms. — INCUBATION. — This  lasts  from  two  to  three  week-. 
During  this  time  there  are  no  peculiar  symptoms,  and  in  many 
cases  the  patient  does  not  suspect  that  anything  is  wrong.  In 
other  cases  there  may  be  a  feeling  of  prostration  with  headache, 
vague  pains,  loss  of  appetite,  and  sleeplessness. 

INVASION. — The  onset  of  typhoid  fever  is  often  so  gradual  and 
insidious  that  the  actual  time  of  beginning  is  not  appreciable  to  the 
patient  Indeed,  in  some  cases  he  may  not  be  indisposed  enough  to 
give  up  business  and  go  to  bed  before  the  fifth  or  sixth  day.  There 
is  not  the  marked  chill  which  ushers  in  many  forms  of  fever,  and 
though  there  may  be  chilly  sensations  in  the  start,  these  do  not 
usually  amount  to  a  pronounced  rigor.  Headache  is  a  more  constant 
and  urgent  symptom,  the  pain  usually  invading  the  frontal  region  at 
first,  though  as  time  passes  it  finally  becomes  more  general.  Attend- 
ing this  there  are  giddiness,  roaring  noises  in  the  ears,  lassitude, 
fugitive  pains,  restlessness  and  insomnia,  loss  of  appetite,  furred 
tongue,  nausea,  epistaiis,  and  usually  diarrhoea,  with  abdominal  pain. 
Attention  to  the  state  of  the  temperature,  during  this  time,  will  dis- 
close the  fact,  usually,  that  it  is  gradually  rising,  each  succeeding 
day  marking  an  advance  upon  the  preceding  one  of  less  than  a  degree, 
and  each  morning  showing  a  remission  of  about  one  degree  below 
that  of  the  previous  evening.  This  gradual  accession  continues  for 
six  or  eight  days,  by  which  time  the  maxtnium  is  reached,  and  the 
increased  pulse-rate  and  arrest  of  secretion  having  been  keeping  in 


TYPHOID  FEVER.  75 

touch  with  the  rise  in  temperature,  a  high  grade  of  pyrexia  has 
finally  been  established. 

The  pulse  is  now  (beginning  of  second  week)  running  from  100 
to  110  per  minute  in  the  evening,  with  slightly  lessened  rate  in  the 
morning  during  the  remission,  the  temperature  ranging  as  high  as 
105°-109°  F.  The  skin  is  hot,  dry,  and  husky,  and  there  is  marked 
restlessness,  the  patient  complaining  bitterly  of  headache,  or  else 
being  delirious  (delirium  first  appearing  during  the  night  to  pass  off 
during  the  following  day,  but  soon  becoming  continuous),  with  noc- 
turnal aggravation;  the  tongue  has  taken  on  evidence  of  encroach- 
ing depravity  of  the  blood,  being  coated  white  with  reddened  tip 
and  edges  or  loaded  with  foul  accumulations,  while  there  may  be 
nausea  and  vomiting,  even  during  the  first  week. 

The  fastigium  is  now  reached,  and  we  find  the  patient  loses  flesh 
and  strength  rapidly.  The  pulse  becomes  dicrotic  and  feeble,  as 
the  heart  loses  power;  the  tongue  becomes  shriveled,  dry,  and  brown. 
Active  delirium  exists,  which  passes  into  a  condition  of  low,  muttering 
semi-coma  in  the  third  week.  Now  occur  stupor,  subsultus,  tremors, 
involuntary  evacuations,  and  other  evidences  of  profound  exhaustion 
and  prostration.  Sordes  collect  upon  the  sides  of  the  mouth  and 
teeth  in  sufficient  quantity  to  form  crusts,  and  become  more  abun- 
dant as  the  disease  progresses.  The  countenance  presents  a  pale, 
leaden  appearance,  with  a  hectic  flush  in  the  center;  the  face  lacks 
expression,  the  patient  sleeping  with  the  mouth  open,  and  tending 
to  slide  downward,  toward  the  foot  of  the  bed. 

The  morning  remissions  become  lengthened  during  the  third 
week,  and  as  these  increase  in  length  and  the  maximum  temperature 
diminishes,  the  morning  decline  finally  reaches  the  normal  during 
the  fourth  loeelc,  the  pulse  gradually  becoming  stronger  and  less  fre- 
quent, the  cerebral  symptoms  disappearing,  and  delirium  giving  way 
to  restful  slumber,  the  tongue  becoming  cleaned  and  moistened,  and 
the  skin  relaxed  and  softened.  During  the  waking  periods  the 
patient  now  (fifth  week)  complains  only  of  prostration  and  hunger, 
his  appetite  and  weakened  mental  condition  conspiring  to  render 
him  peevish  and  exacting,  in  matters  pertaining  to  a  proper  diet. 

As  early  as  the  first  week — by  the  sixth  day — there  will  be  found 
pain  and  tenderness  in  the  right  iliac  fossa.  Slight  pressure  elicits 
pain  now,  attended  with  gurgling,  and  the  sensitiveness  becomes 
more  marked  as  the  disease  progresses.  Examinations  of  this  char- 
acter should  be  made  with  the  palm  of  the  hand,  and  the  pressure 
be  gentle.  By  the  beginning  of  the  second  week  tympanites  begins 
to  appear,  the  abdomen  gradually  becoming  distended  and  drum- 
like.  This  usually  becomes  extreme  as  the  disease  advances,  being 


76  SPECIFIC  INFECTIOUS  DISEASES. 

due  to  a  collection  of  gas  in  the  large  intestine.  The  tympanites  is 
an  indication  of  serious  pathological  change  in  the  alimentary  canal, 
and  so  lon^  as  it  continues  it  is  patent  evidence  that  the  patient  is 
in  a  precarious  condition. 

A  common  though  not  constant  symptom  of  typhoid  fever  is 
diarrhoea.  This  may  be  present  during  the  first  week,  but  may  not 
appear  until  the  third,  though  it  is  liable  to  be  most  prominent  dur- 
ing the  second.  The  evacuations  are  peculiar,  being  of  a  greenish- 
yellow  color,  aud  being  described  as  "pea-soup  discharges." 
Sometimes  they  are  dark  in  color,  resembling  coffee-grounds.  They 
are  alkaline  in  reaction,  and  upon  standing  deposit  a  granular  sedi- 
ment, the  upper  portion  being  watery  in  character.  In  mild  typhoids, 
as  well  as  in  some  severe  ones,  diarrhoaa  may  be  absent. 

Intestinal  hemorrhage  is  said  to  occur  once  in  about  every 
twenty  cases.  It  is  the  result  of  sloughing  of  an  artery  in  the  intes- 
tinal wall,  and  is  a  very  dangerous  complication.  The  hemorrhage 
may  occur  without  any  external  evidence  of  the  discharge,  rapid  fall 
of  temperature  and  great  prostration  attending.  In  other  cases,  the 
blood  flows  in  large  quantity  from  the  boweL  Slight  hemorrhages 
from  the  mucous  membrane  of  the  bowel  may  occur  early  in  the 
disease,  but  they  are  of  trivial  consequence,  as  they  consist  merely 
of  capillary  oozing,  similar  to  that  of  the  early  epistaxis.  Arterial 
hemorrhage  rarely  occurs  earlier  than  the  latter  part  of  the  second 
week,  and  is  more  likely  to  occur  during  the  third.  If  the  intesti- 
nal structures  be  fortified  during  the  preceding  time,  there  is  dimin- 
ished risk  that  this  accident  will  occur.  The  treatment  from  the 
beginning  should  look  toward  a  favoring  of  the  integrity  of  the 
intestinal  structures. 

Between  the  seventh  and  twelfth  days  the  characteristic  eruption 
appears.  It  is  found  most  abundant  upon  the  abdomen  and  chest, 
but  may  be  isolated  over  other  parts  of  the  body.  It  appears  in 
minute,  round,  rose-colored  spots,  slightly  elevated  above  the  general 
surface,  disappearing  upon  pressure,  but  returning  immediately  after- 
ward. Each  spot  remains  visible  for  three  days,  but  successive 
crops  may  appear  during  a  period  of  ten  or  twelve  days.  In  some 
cases  they  are  so  faintly  marked  that  great  care  may  be  necessary  in 
order  to  <letect  them.  They  possess  little  significance  therapeutic- 
ally,  but  are  considered  a  diagnostic  symptom  of  true  typhoid  fever, 
by  many.  They  are,  however,  sometimes  absent. 

During  the  first  two  weeks,  the  urine  is  scanty  and  dark  colored, 
and  shows  a  high  specific  gravity;  after  the  second  week  the  quantity 
is  increased,  and  during  convalescence  it  becomes  pale  and  abundant, 
and  its  specific  gravity  is  lowered.  It  is  asserted  that  upon  an  aver- 


TYPHOID  FEVER.  77 

age  the  amount  of  urine  voided  during  typhoid  fever  is  greater  than 
the  normal  amount  during  the  same  length  of  time ;  but  this  is  prob- 
ably due  to  the  fact  that  the  diet  is  largely  liquid  now.  thus  provid- 
ing for  a  greater  amount  of  fluids  in  the  body.  Albumin  is  occasion- 
ally found  in  the  urine  of  typhoid  patients,  though  not  in  many 
instances. 

The  nervous  symptoms  of  typhoid  fever  are  prominent  through- 
out its  course,  in  most  instances.  The  mental  symptoms  during  the 
early  part  of  the  disease  are  often  those  of  apathy,  the  patient  being 
torpid,  careless,  and  unimpressible,  answering  questions  slowly,  and 
giving  little  heed  to  his  surroundings.  In  other  cases,  however, 
extreme  restlessness  may  be  manifested  in  the  start,  the  patient 
changing  his  position  frequently,  tossing  about  almost  constantly,  and 
failing  to  find  rest  anywhere.  Active  delirium  often  sets  in  with 
the  establishment  of  the  fastigium,  it  sometimes  being  necessary  to 
employ  force  to  prevent  the  patient  from  doing  himself  or  his  attend- 
ants harm.  At  other  times,  though  this  condition  is  liable  to  come 
on  later,  there  is  more  of  a  subdued  delirium,  characterized  by 
dreamy  aberrations  attended  by  incoherent  mutterings — typhoma- 
nia.  This  condition  is  pretty  well  established  by  the  latter  part  of 
the  third  week  or  fore  part  of  the  fourth.  Gradually,  in  favorable 
cases,  this  passes  into  a  somnolent  condition,  and  the  fever  runs  its 
last  few  days  and  terminates  with  the  patient  sleeping  most  of  the 
time. 

The  special  senses  are  often  involved.  Impairment  of  hearing  is 
a  common  symptom,  it  being  necessary  to  speak  above  the  ordinary 
tone  to  elicit  an  answer.  Vision  is  also  impaired,  for  a  time,  in  many 
cases.  Paralysis  of  the  sphincters  is  a  prominent  symptom  in  some 
instances,  the  evacuations  passing  involuntarily,  and  necessitating 
the  use  of  diapers  to  protect  the  bedding,  while  in  other  cases  reten- 
tion of  urine  from  loss  of  vesical  power  may  demand  the  regular  use 
of  the  catheter. 

TEMPERATURE. — The  temperature  of  typhoid  fever — the  typical 
temperature — shows  a  gradual  rise  of  a  little  less  than  a  degree  per 
day  above  the  maximum  of  the  preceding  one,  with  a  morning  remis- 
sion of  one  degree  for  the  first  week  or  about  eight  days.  Dur- 
ing the  second  waek  the  maximum  of  each  day  remains  about  the 
same  as  that  marked  on  the  eighth  day,  with  a  morning  remission  of 
near  one  degree.  During  the  third  week  the  remissions  become  more 
marked,  though  the  maximum  still  remains  at  about  the  same  height. 
During  the  fourth  week  the  remissions  become  still  more  marked, 
while  the  maximum  declines  day  by  day,  until  the  normal  line  is 
reached  during  the  decline,  actual  intermissions  finally  occurring. 


78  SPECIFIC  INFECTIOUS  DISEASES. 

During  the  last  two  or  three  days  of  decline,  the  periods  corre- 
sponding to  the  morning  remissions  may  be  marked  by  slight  sub- 
normal temperature,  and  this  may  continue  into  convalescence. 

Usually  the  temperature  begins  to  rise  about  the  middle  of  the 
day  on  the  first  day  of  the  fever,  and  the  exacerbation  continues 
until  six  or  eight  o'clock  in  the  evening,  when  it  remains  stationary 
until  about  midnight;  then  it  begins  to  decline  and  continues  to  do  so 
uutil  six  or  eight  o'clock  the  following  morning,  when  the  minimum 
of  the  remission  is  reached  for  that  day;  the  temperature  now 
remains  about  at  this  point  until  the  middle  of  the  day,  when  it 
again  begins  to  rise,  and  remains  elevated  until  midnight,  as  before, 
when  it  again  begins  to  decline,  continuing  to  do  so  until  six  or 
eight  o'clock  in  the  morning,  when  it  remains  about  stationary  until 
the  following  noontime,  when  it  again  rises  as  before.  This  rotation 
of  rise  and  decline — the  temperature  rising  a  degree  higher  than  the 
maximum  of  the  preceding  day  and  falling  about  a  degree  each 
intermission — thus  continues  for  the  first  week. 

While  such  is  the  usual  course  of  the  disease,  marked  variations 
may  occur  as  the  result  of  complications,  and  these  variations  may 
often  be  considered  as  the  most  positive  index  of  such  complica- 
tions. Treatment  may  modify  the  temperature  very  much,  and  some 
drugs,  as  antifebrin,  possess  the  power  of  lowering  the  temperature 
rapidly,  though  not  always  safely.  Belapses  are  not  uncommon  in 
typhoid  fever,  and  are  marked  by  gradual  rise  of  temperature. 
Intestinal  hemorrhage,  when  profuse,  is  usually  marked  by  a  sudden 
fall  of  temperature,  to  the  extent  of  two  or  three  degrees.  When 
this  fall  occurs  during  the  second  or  third  week,  and  is  accompanied 
by  marked  prostration,  it  is  pretty  good  evidence  that  an  artery  has 
been  opened  in  some  intestinal  ulcer,  and  that  profuse  hemorrhage 
has  occurred,  even  though  no  blood  has  been  voided  in  the 
dejections.  Perforation  of  the  bowel  is  soon  followed  by  a  rapid 
decline  of  temperature,  which  is  succeeded  by  abrupt  and  extreme 
elevation,  and  collapse. 

Occasionally,  the  stage  of  invasion  is  abruptly  announced  by  a 
sharp  chill,  which  is  followed  by  a  high  temperature  without  the 
gradual  rise,  the  case  opening  at  once  into  tLe  fastigium.  When 
malarial  complication  exists,  the  temperature  may  resemble  that  of 
intermittent  fever  until  the  abdominal  lesions  develop,  there  being 
a  daily  chill,  followed  by  fever  and  sweating,  for  the  first  week. 

Cases  in  which  the  temperature  declines  to  normal  at  the  close 
of  the  second  week  are  spoken  of  as  "aborted  typhoids,"  the  early 
convalescence  being  due  to  the  fact  that  the  intestinal  lesions  sub- 
side without  going  on  to  ulceration. 


1YPHOID  FEVER 


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80  SPECIFIC  INFECTIOUS  DISEASES. 

Relapses  and  recrudescences  are  not  to  be  overlooked.  Relapse  s 
are  due  to  reinfection  of  the  intestine  from  sloughs  which  have  been 
cast  off  from  above,  in  cases  which  have  not  received  proper  medica- 
tion during  the  first  attack.  They  are  not  common,  but  are  said  to 
occur  in  from  3  to  18  per  cent  of  all  cases,  though  exceedingly  rare 
in  Eclectic  practice.  If  they  occur  during  the  fastigium,  there  is 
merely  a  prolongation  of  the  stage  of  active  fever.  Most  frequently 
they  occur  from  five  to  eight  days  after  the  termination  of  the  pri- 
mary attack,  though  this  period  may  be  prolonged  to  twenty-five 
days.  When  they  thus  occur,  the  temperature  curve  is  repeated, 
though  it  is  very  much  shortened,  the  stage  of  invasion  ending  in 
from  three  to  five  day.-,  and  the  other  stages  accordingly,  ten  to  four- 
teen days  being  occupied  in  this  second  course.  Recrudescences  are 
temporary  rises  of  temperature  occurring  during  convalescence, 
from  dietary  indiscretions  or  overexertion.  These  occur  suddenly, 
and,  in  favorable  cases,  terminate  in  from  one  to  five  days. 

During  convalescence,  the  temperature  may  remain  persistently 
elevated  two  or  three  degrees  for  several  weeks,  this  being  due  to 
unhealed  ulcers  in  the  intestine,  which  only  recover  by  slow  stages. 

Diagnosis. — The  regular  and  gradual  rise  in  temperature  and 
morning  remission  during  the  first  week,  the  abdominal  tenderness 
and  intestinal  irritation,  the  rash,  and  the  infectious  character  of  the 
disease,  will  be  sufficient  to  warrant  the  diagnosis.  It  might  be  sup- 
posed that  as  this  disease  is  dependent  upon  the  presence  of  the 
typhoid  bacillus  in  the  alimentary  canal,  a  microscopical  examination 
of  the  dejections  would  readily  settle  the  question  in  any  doubtful 
case.  But  it  seems  that  there  are  many  difficulties  in  the  way  of 
detecting  these  bacteria  here,  and  that  it  is  only  in  a  small  propor- 
tion of  the  cases  that  they  can  positively  be  identified.  Dr.  Adolph 
Gehrmann,  an  authority  upon  bacteriolgy,  remarks  (Fort  Wayne 
Medical  Magazine}: 

"Reported  demonstrations  of  the  isolation  of  typhoid  bacillus 
from  the  evacuations  of  patients  are  not  numerous.  Pfeiffer,  Kar- 
linski,  Fraeukel  and  Simons  have  so  reported.  In  the  case  of  the 
last-named  experimenters,  out  of  eleven  separate  attempts  by  means 
of  direct  cultivation  by  Koch's  plate  method,  success  was  attained  in 
but  three  instances.  The  diagnosis  here  was  made  \>y  obtaining 
cultures  of  typhoid  bacillus  by  selecting  colonies  on  the  plate  cul- 
tures peculiar  to  that  organism.  A  method  of  this  kind  is  most  diffi- 
cult, as  only  the  smallest  quantity  of  discharges  can  be  taken,  and  the 
dilution  must  be  extreme,  in  order  to  separate  them  widely  enough 
to  obtain  isolated  colonies.  Where  bacteria  of  all  kinds  are  in  such 
great  numbers,  there  must  first  be  some  quick  means  of  separating 


TYPHOID  FEVER.  81 

the  organism  in  question  from  all  others,  and  lastly  some  means  of 
establishing  its  identity.  The  separation  of  typhoid  bacillus  from 
the  majority  of  its  associated  bacteria  is  not  a  matter  of  great  diffi- 
culty, but  its  final  identification  has  proven  a  most  serious  obstacle. 
Typhoid  bacillus  is  not  a  distinctive  species.  Its  similarity  to  bacil- 
lus coli  communis  is  so  close  that  the  proposed  distinctive  features 
have  been  overthrown,  one  after  another.  Apparently  there  is  a 
group  of  bacteria  haviug  typhoid  bacillus  at  one  extreme  and  bacil- 
lus coli  at  the  other,  while  between  them  is  a  gradually  changing 
series  of  va.rieties.  Much  more  time  has  been  devoted  to  the  study 
of  these  peculiarities  and  to  the  presence  of  the  group  in  water  sup- 
plies, than  to  the  relation  of  these  bacteria  to  the  intestinal  canal. 
This  variability  of  typhoid  bacillus  has  always  occasioned  the  great- 
est difficulty  in  studying  the  biology  of  the  organism  itself,  or  in 
investigating  the  cause  and  nature  of  the  disease." 

Prognosis. — Though  a  disease  cf  grave  aspect,  the  mortality, 
under  proper  treatment,  ought  not  to  be  great.  In  ordinary  epidem- 
ics, 5  or  6  per  cent  ought  to  be  a  large  death  rate,  where  modern 
Eclectic  methods  of  treatment  are  pursued.  There  is  a  marked 
difference  in  the  severity  of  different  epidemics,  the  abdominal  symp- 
toms being  exceptionally  severe  in  some,  while  in  others  the  cerebral 
symptoms  are  aggravated.  Hospital  reports  usually  show  a  larger 
percentage  of  deaths  than  commonly  occur  in  the  private  practice  of 
Eclectic  physicians,  and  the  custom  of  recommending  such  patients 
to  the  care  of  hospitals  is  not  to  be  commended.  During  a  recent 
epidemic  of  typhoid  fever  in  this  city  (Oakland),  the  mortality  in 
Fabiola  Hospital  (Homeopathic)  was  remarkably  great,  though  not 
many  deaths  occurred  in  private  practice,  and  these  almost  entirely 
under  old  school  treatment. 

Hyperpyrexia,  aggravated  delirium,  hemorrhage,  and  peritonitis, 
are  unfavorable  symptoms,  and  should  lead  to  a  guarded  prognosis. 

Treatment. — The  treatment  of  typhoid  fever  may  be  divided 
into  preventive  and  restorative.  At  the  commencement  of  an  epidemic, 
the  conscientious  physician  will  make  early  inquiry  into  the  origin 
of  the  disease,  and  &ee  that  as  few  persons  as  possible  are  exposed  to 
the  infection.  In  rural  districts,  the  water  supply  is  usually  the 
source  of  contamination,  the  disease  having  previously  been  com- 
municated to  some  well  or  spring  from  which  the  family  or  families 
affected  are  using,  all  who  drink  the  water  receiving  the  germs  into 
their  systems.  In  cities,  such  water  may  be  used  to  dilute  the  milk 
distributed  before  it  is  conveyed  from  the  country,  or  in  washing  the 
cans  in  which  it  is  transported,  and  the  disease  thus  be  distributed. 
In  such  cases,  the  health  officer  who  does  his  duty  will  see  that  the 


82  SPECIFIC  INFECTIOUS  DISEASES. 

supply  of  milk  containing  the  germs  of  the  disease  is  ferreted  out, 
and  shut  off  by  strict  quarantine.  Wells  or  springs  suspected  or 
known  to  be  contaminated,  should  be  avoided,  and  where  there  is 
positive  evidence  that  such  a  place  has  been  vitiated,  it  should  be 
filled  up  and  a  new  one  dug.  Wells  or  springs  in  the  neighborhood 
of  privies,  barn-yards  or  sewers,  should  be  looked  upon  with  suspi- 
cion, and  the  water  avoided. 

As  the  specific  poison  exists  in  the  evacuations  of  typhoid 
patients,  great  care  is  demanded  during  the  course  of  the  disease 
that  these  be  so  treated  that  there  will  be  no  possibility  of  contami- 
nation resulting  from  them.  A  porcelain  bedpan  should  receive  the 
discharges,  and  before  use  this  should  be  charged  with  half  a  pint 
of  saturated  solution  of  sulphate  of  iron  or  copper.  A  more  conven- 
ient plan,  considering  the  preservation  of  the  bed,  is  to  sprinkle  the 
bottom  of  the  vessel  over  with  dry  powdered  sulphate  of  copper, 
while  immediately  after  the  evacuation  crude  muriatic  acid  or  a 
strong  solution  of  copperas  is  added.  It  should  now  be  allowed 
to  stand  a  sufficient  length  of  time  for  the  chemicals  to  react  thor- 
oughly upon  the  morbid  material.  The  disposal  of  the  contents  of 
the  pan  is  an  important  consideration.  When  possible  to  do  so,  it 
should  be  emptied  into  a  trench  and  immediately  covered,  new 
trenches  being  du^  frequently.  Care  should  be  observed  to  see  that 
the  fecal  material  is  not  emptied  upon  the  surface  of  the  ground,  nor 
deposited  near  the  well  or  spring  from  which  drinking  water  is 
obtained.  If  it  becomes  necessary  to  empty  the  evacuations  into  a 
closet-trap,  this  should  be  frequently  scalded  with  boiling  water, 
and  none  should  be  emptied  here  until  thoroughly  disinfected. 

Care  should  be  taken  regarding  the  disposal  of  cloths,  wearing 
apparel,  and  bedding,  which  may  be  soiled  by  the  discharges,  that  no 
contamination  is  conveyed  to  the  non-infected.  Cloths  of  no  particu- 
lar value  may  be  burned,  and  other  fabrics  should  be  immediately 
washed,  being  thoroughly  boiled  during  the  process  of  cleansing. 
A  very  good  plan  would  be  to  immerse  the  clothing  in  a  1—1000 
solution  of  bichloride  of  mercury  before  any  attempt  at  cleansing 
was  made,  the  immersion  to  be  continued  an  hour.  Nurses  should 
be  careful  about  communicating  the  infection  with  their  hands. 

The  rooms  occupied  by  typhoid  fever  patients  should  be  free 
from  opportunity  for  the  breeding  of  fomites.  Carpets  and  tapestry 
would  be  best  dispensed  with,  as  well  as  all  furniture,  except  such 
as  is  needed  for  patient  and  nurse.  There  should  be  a  free  sup-, 
ply  of  pure  air,  though  the  temperature  should  not  be  far  below 
60°  P.  The  room  should  be  kept  quiet,  and  all  causes  of  disturbance 
to  the  patient  avoided. 


TYPHOID  FEVEli.  83 

In  order  to  avoid  any  chance  of  injury  to  the  bowel,  the  diet 
should  be  liquid  in  character,  rice  water  and  malted  mil1^  or  Mellin's 
food  constituting  the  principal  part,  all  solid  food  being  dispensed 
with;  and  fruits  should  not  be  allowed  under  any  consideration. 
The  food  should  be  given  at  regular  intervals,  as  promptly  and  regu- 
larly as  medicine,  and  in  small  quantities,  repeated  as  often  as  every 
two  or  three  hours. 

Owing  to  the  marked  debility  of  the  tissues  brought  about  during 
this  disease,  and  the  tendency  to  hypostatic  congestion  resulting,  the 
patient  should  not  be  allowed  to  remain  for  any  considerable  length 
of  time  in  one  position.  As  he  is  liable  to  soon  become  helpless 
and  unconscious,  the  nurse  should  be  instructed  to  turn  him  from 
side  to  side  and  from  side  to  back  frequently,  especially  during  the 
day,  and  this  precaution  should  be  so  observed  that  he  shall  not 
remain  in  one  position  more  than  four  hours  at  a  time,  unless  intes- 
tinal hemorrhage  or  other  complication  render  it  inadvisable  to  dis- 
turb him.  In  all  manipulation,  the  delicate  condition  of  the  bowels 
should  be  recollected,  that  injury  be  not  added  to  that  inflicted  by 
the  pathological  changes  which  are  going  on. 

Good  nursing  shows  a  better  record  of  mortality  in  the  manage- 
ment of  this  disease  than  that  of  old.  and  harsh  methods  of  treat- 
ment. Cathartics  should  be  carefully  avoided.  Opiates  and  mercu- 
rials are  dangerous  in  the  extreme.  Quinine  and  other  bitter  tonics, 
as  well  as  stimulants,  should  only  come  in  late  in  the  course  of  the 
disease  or  during  convalescence,  if  at  alL 

What  are  the  rational  therapeutic  indications  in  the  treatment  of 
this  affection?  Where  do  we  find  the  most  marked  evidence  of  mor- 
bid action?  Evidently,  the  severity  of  the  affection  is  manifested 
upon  the  intestinal  structures,  and  the  case  becomes  grave  in  pro- 
portion as  the  pathological  changes  here  are  marked.  It  is  true 
that  there  may  be  a  cerebral  complication  in  isolated  cases  which 
will  render  the  prognosis  serious  where  the  abdominal  symptoms 
are  not  severe,  but  this  is  hardly  the  rule,  and  is  a  rare  exception. 
If  we  will  direct  the  excellent  means  at  our  command  to  the  relief 
of  intestinal  irritation,  and  to  the  fortifying  of  this  part  against 
pathological  changes  from  the  very  beginning,  we  shall  not  find 
many  cases  to  present  very  grave  features. 

There  are  two  remedies  which  I  think  we  may  employ  for  this  pur- 
pose with  a  great  amount  of  confidence,  viz.,  baptisia  and  echinacea. 
It  is  not  necessary  that  we  discriminate  particularly  as  to  "specific 
indications"  in  differentiating  between  the  use  of  these  agents  here. 
Bolh  possess  a  relation  of  a  restorative  character  to  sloughing  mucous 
membranes,  and  a  restorative  character  where  necrotic  conditions 


84  SPECIFIC  INFECTIOUS  DISEASES. 

are  present  or  threatened,  anil  both  are  recognized  as  valuable  anti- 
septics. Echinacea  is  a  remedy  of  especially  valuable  properties  where 
a  sedative,  antiseptic,  restorative,  and  vital  stimulant  ar^  required 
in  the  one  agent,  and  its  excellent  effects  where  meningeal  irrita- 
tion is  present  is  an  additional  recommendation.  I  believe  that 
most  cases  of  typhoid  fever  may  be  safely  trusted  to  the  action  of 
this  remedy  alone. 

As  there  will  probably  be  a  demand  for  other  treatment,  we  will 
not  obstruct  the  opportunity  for  further  medication  by  alternating 
these-,  but  will  administer  them  in  combination.  To  half  a  tumbler 
of  water  add  a  drachm  of  baptisia  and  two  or  three  drachms  of  ech- 
inacea,  and  order  a  teaspoonful  every  two  hours.  We  will  let  this 
combination  be  the  basic  remedy,  and  will  continue  it  until  conva- 
lescence has  been  announced  by  a  normal  temperature.  It  would 
not  usually  be  a  pleasant  combination,  as  to  taste,  but  the  typhoid 
patient  will  make  no  objection  to  it,  as  his  sense  of  taste  has  prob- 
ably been  abolished,  for  the  time. 

With  this  treatment  directed  toward  the  prominent  pathological 
lesion,  we  will  hold  our  reserves  in  readiness  for  such  complications 
as  may  arise. 

HYPERPYREXIA, — A  prominent  and  serious  symptom  of  many 
cases  of  typhoid  fever  is  an  excessively  high  temperature.  Kapid 
destruction  of  tissue  must  result  in  such  cases,  and  danger  to  tissues 
naturally  jeopardized,  such  as  the  intestinal  walls  and  brain,  is  very 
much  increased.  When  the  maximum  temperature  is  above  106°  F. 
during  the  stadium,  the  condition  may  be  considered  hyperpyretic. 
There  are  various  opinions  among  physicians  of  our  faith  respecting 
the  proper  treatment  of  this  condition.  Professor  Seudder  taught,  and 
he  has  many  followers  who  agree  with  him,  that  the  febrile  feature 
of  typhoid  fever  is  successfully  met  by  the  use  of  the  special  seda- 
tives— aconite,  veratrum,  and  gelsemiuin.  The  argument  is  that 
these  remedies,  properly  adapted,  administered  in  minute  doses, 
and  frequently  repeated,  control  and  strengthen  the  action  of  the 
heart  and  bloodvessels,  lessen  excitement,  and  promote  secretion, 
thus  lowering  the  maximum  of  the  temperature  throughout  the 
course  of  the  fever.  I  have  been  a  believer  in  this  doctrine  myself, 
and  I  am  satisfied  that  the  plan,  if  not  overdone,  is  followed,  in  a 
large  percentage  of  the  cases,  with  successful  results.  Where  this 
plan  is  to  be  pursued,  the  proper  remedy  should  be  selected  upon 
certain  well-knowu  principles  (see  author's  "Principles  of  Medicine"), 
and  administered  in  minute  doses  at  frequent  intervals  throughout 
the  course  of  the  disease. 

However,  while  I  am  a  firm  believer  in  the  special  sedative  treat- 


TYPHOID  FEVER.  85 

ment  of  fevers  generally,  my  recent  experience  has  led  me  to  believe 
that  little  real  benefit  foUows  the  practice  in  tlie  management  of 
this  form  Typhoid  fever  is  a  mild  form  of  septicaemia,  and  seems 
unimpressibls  ly  such  means,  when  compared  with  results  in  other 
forms.  The  thermometer  will  not  manifest  any  decided  impression 
from  this  plan  of  treatment  in  the  majority  of  cases.  Still,  there  is 
no  gainsaying  the  fact  that  these  remedies  may  improve  the  patient's 
chances,  by  soothing  nervous  excitement  and  promoting  rest — short- 
ening the  period  of  active  delirium. 

What  I  consider  a  more  pronounced  antipyretic  in  such  cases  as 
are  here  under  consideration  (hyperpyretic),  is  the  salicylate  of 
ammonium.  The  formula  is  as  follows,  though  the  salt  may  now  be 
obtained,  prepared,  in  the  drug  market: 

R  Salicylic  acid,  jii ;  carbonate  of  ammonium,  jiii;  aquse  menth. 
piper.,  ffiv.  M.  Dose,  a  teaspoonful. 

This  may  be  administered  every  two  hours,  in  alternation  with  the 
combination  of  baptisia  and  echinacea,  until  the  temperature  has 
fallen  below  that  of  hyperpyrexia.  Indeed,  this  remedy  may  be 
continued  throughout  the  course  of  the  disease  with  gratifying 
effect,  in  many  instances. 

Another  excellent  means  in  hyperpyrexia,  and  one  which  may  be 
used  in  conjunction  with  this  or  employed  ind  pendently,  is  the  cold 
abdominal  pack.  This  may  envelop  the  entire  form,  but  one  large 
enough  to  reach  from  th^  axillae  to  the  thighs  will  usually  afford  bet- 
ter satisfaction.  The  bed  is  protected  w^h  an  oilclo  h  or  rubber 
blanket,  and  half  a  sheet  is  wrung  out  of  cold  water  and  wrapped 
about  the  body  as  already  suggested,  to  be  renewed  every  two  hours, 
until  no  longer  needed.  A  good  substitute  for  this  application  is  a 
large  clyster  of  cold  water,  though  here  the  patient  must  aid  in 
retaining  it,  a  condition  requiring  possession  of  the  mental  faculties, 
and  one  not  always  available.  In  making  use  of  rectal  injections 
here,  the  weakened  condition  of  the  bowel  must  "be  borne  in  mind, 
and  the  application  of  much  force  carefully  avoided. 

The  administration  of  large  doses  of  quinine  for  the  purpose  of 
lowering  the  temperature  in  these  cases  has  been  strongly  advocated 
by  certain  old  school  authors,  and  some  reputable  writers  of  our 
own  school  have  indorsed  the  doctrine.  My  experience  has  been 
that  such  medication  usually  aggravates  cerebral  symptoms,  and 
does  not  markedly  lower  the  temperature.  However,  circumstances 
alter  cases,  and  it  may  be  possible  that  certain  epidemics  or  certain 
localities  m;iy  present  us  with  cases  where  such  treatment  woulJ.  be 
strictly  the  proper  thing.  However,  I  would  enjoin  caution  in  this 
method  until  the  fact  was  proven  clinically  in  at  least  one  case  of  an 


86  SPECIFIC  INFECTIOUS  DISEASES. 

epidemic,  before  beginning  the  indiscriminate  use  of  quinine  as  an 
antipyretic  in  typhoid.  As  a  general  rule,  the  proposition  is  bad. 

There  nre  those  who  extol  acetanilide  as  an  excellent  remedy  for 
this  purpose.  It  is  asserted  that  an  immediate  fall  of  temperature 
follows  the  administration  of  from  three  to  five  grains,  and  that  a 
period  of  two  or  three  days  ensues  before  the  temperature  rises  to 
H  point  demanding  a  repetition  of  the  close.  But  it  is  to  be  remera- 
b:red  that  this  remedy  is  markedly  depressing,  and  upon  theory, 
not  a  desirable  agent  to  administer  in  such  a  condition  of  prostra- 
tion as  is  found  in  this  disease.  It  would  be  fair  to  expect  a  large 
mortality  to  attend  such  treatment,  even  though  we  be  assured  that 
such  is  not  the  case.  I  would  be  inclined  to  regard  this  remedy 
with  grave  suspicion,  however,  until  fully  convinced  by  observation 
of  some  one  el-e's  practice  that  the  vaunted  benefits  can  positively 
be  derived  with  safety. 

DELIRIUM. — The  delirium  of  typhoid  fever  is  sometimes  appall- 
ing. The  patient  may  be  so  furious  as  to  seemingly  force  the  respon- 
sibility upon  the  physician  of  attempting  to  control  the  ravings  with 
drugs.  As  this  goes  on  day  after  day,  attendants  or  friends  may 
urgently  ask  th&t  strong  drugs  be  used  to  promote  slumber.  In 
such  cases  the  physician  must  preserve  the  greatest  moderation  as 
to  the  character  of  his  medication,  seeing  that  active  narcotics  are 
strictly  avoided,  as  there  could  hardly  be  a  more  dangerous  place 
for  their  exhibition.  It  may  be  true  that  attendants  become  worn 
out  in  their  efforts  to  prevent  the  patient  from  leaving  his  bed,  and 
it  may  seem  that  the  efforts  of  the  patient  himself  may  end  in  fatal 
exhaustion,  but  there  is  much  less  danger  of  this  than  of  the  effects 
of  opiates.  Minute  doses  of  aconite  and  rhus  tox.  may  afford  some 
benefit,  or  small  doses  of  belladonna,  3x  dilution.  Possibly,  though 
not  probably,  small  doses  of  bromides  may  benefit.  Passiflora  is  not 
of  much  use  as  a  calmative  during  febrile  action.  Sulfonal  may  ben- 
efit some,  but  is  not  likely  to.  Cold  cloths  to  the  head,  anil  some- 
times ice-bags,  may  afford  good  results.  The  general  condition  and 
benefit  of  the  patient  should,  however,  always  be  held  paramount  to 
that  of  special  means  for  the  relief  of  what  is  but  one  of  the  phases 
which  this  fever  almost  always  presents.  In  due  time  the  active 
delirium  gives  way  to  that  dreamy  wandering  consequent  upon  the 
exhausting  effects  of  the  first  onset,  and  the  better  the  management 
has  been  up  to  this  time  the  better  the  patient's  chances  will  be  to 
survive  the  further  ordeal.  Sometimes,  where  there  are  presented 
quite  vividly  the  indications  for  gelsemium — flushed  face,  bright 
eyes  with  contracted  pupils,  full,  bounding  j>uls>,  etc.,  the  zealous 
Eclectic  (or  specific  inedicationist)  may  be  tempted  to  push  this 


TYPHOID  FEVER.  87 

drug  beyoud  safe  bounds,  and  cause  debility  of  the  circulation,  from 
which  the  patient  may  rally  with  difficulty.  It  is  well  to  remember 
that  recovery  from  this  fever  is  a  sort  of  evolution,  through  which 
the  proper  treatment  consists  in  safely  guiding  the  case  to  a  success- 
ful issue  by  fostering  the  processes  of  life  so  far  as  possible,  and 
avoiding  all  measures  which  might  interfere  with  the  best  perform- 
ance of  these  functions. 

The  beneficial  effects  of  tepid  baths  in  such  cases  should  nofc  be 
forgotten.  The  restlessness  and  furor  of  the  stage  of  active  delirium 
should  be  met  with  frequent  sponging,  and  the  nurse  should  possess 
the  requisite  knowledge  to  prompt  persistent  resort  to  this  measure. 
Sponge  baths  should  be  applied  several  times  a  day,  and  it  will  soon  be 
noticed  that  the  patient  rests  better,  for  a  time,  after  this  application. 

GASTRIC  COMPLICATIONS. — The  stomach  is  frequently  disturbed  by 
morbid  conditions  which  interfere  with  the  action  of  remedies. 
Gastric  irritation  may  le  present,  marked  by  nausea,  rejection  of 
food  and  medicine,  and  restlessness;  the  tongue  will  be  pointed, 
and  reddened  afc  the  tip.  Here  we  will  usually  be  able  to  correct 
the  condition  with  small  doses  of  aconitj  and  rhus  tox.,  and  it  may 
seem  best  to  dispense  with  all  other  treatment  for  a  day  or  two, 
until  the  stomach  has  become  well  settled.  Add  ten  or  fifteen  drops 
of  rhus  tox.  and  five  drops  of  aconite  to  half  a  glass  (four  ounces) 
of  water,  and  order  a  teaspoonful  every  hour.  This  may  possibly 
fail  after  a  fair  tria1,  but  is  hardly  likely  to;  however,  two  grains  of 
subnitrate  of  bismuth  every  two  hours  may  then  be  tried,  and,  in 
event  of  failure  with  this,  minute  doses  of  ipecac  or  peach  bark 
infusion. 

Another  gastric  complication  which  is  very  common  in  the 
course  of  typhoid,  is  excessive  acidity  of  the  stomach.  This  is 
marked  by  the  broad,  flabby  tongue,  evenly  and  thickly  coated  with 
a  pasty  white  coating.  As  sepsis  is  more  or  less  marked  there  will 
be  an  element  of  color  in  this  coating,  it  often  being  described  as 
"dirty."  Sodium  sulphite  is  here  the  corrective,  and  this  agent 
should  be  administer  d  in  one-  or  two-grain  capsules,  every  two  or 
four  hours  until  the  tongue  cleans  or  presents  a  different  aspect. 
It  is  important  to  correct  such  a  condition  in  order  that  other  rem- 
edies may  be  readily  appropriated. 

SPECIAL  SEPTIC  CONDITIONS. — While  typhoid  fever  is  of  itself 
a  markedly  septic  disease,  and  while  the  use  of  echinacea  and  bap- 
tisia  has  been  advised  throughout,  partly  for  their  antiseptic  influ- 
ence, there  are  special  conditions  liable  to  arise  which  may  demand 
other  remedies  of  this  class,  though  not  likely  to  be  marked  if  these 
remedies  are  c  mtinu  >d  from  the  beginning.  Sulphurous  acid  is  an 


88  SPECIFIC  INFECTIOUS  DISEASES. 

agent  which  is  sometimes  urgently  demanded  in  the  treatment  of 
this  disease.  The  condition  which  requires  it  is  indicated  by  brown 
coating  on  the  tongue  and  sordes  on  the  lips  and  teeth;  here  sulphu- 
rous acid  should  be  given  in  twenty-  or  thirty-drop  doses,  well  diluted, 
every  two  or  three  hours.  The  beefsteak  tongue — clean,  dark-red, 
slick — may  appear  toward  time  of  convalescence,  and  will  demand 
the  use  of  mild  acids,  such  as  acid  drinks  or  dilute  muriatic  acid. 
Of  the  latter,  ten  to  twenty  drops  may  be  given  every  four  hours, 
until  the  characteristic  condition  of  the  tongue  has  given  way  to  a 
natural  appearance. 

DIARRHCEA. — This  symptom  is  a  very  common  one  in  typhoid,  and 
one  which  it  might  seem  necessary  to  control.  However,  it  is  to  be 
recollected  that  it  is  but  a  result  of  the  catarrhal  inflammation  of 
the  mucous  membrane  of  the  lower  bowel,  and  the  rational  manage- 
ment will  consist  in  the  use  of  means  which  will  control  the  intesti- 
nal irritation,  to  which  we  have  already  directed  echinacea  and 
baptisia.  There  would  be  no  logic  in  attempting  to  control  this 
difficulty  with  astringents;  and  it  would  only  be  a  return  to  the  crude 
practice  of  obsolete  medicine.  Salol  has  been  highly  recommended 
in  certain  quarters,  on  account  of  its  antiseptic  influence  in  intestinal 
sepsis.  But  the  advocates  of  this  remedy  are  those  who  are  not 
acquainted  with  Eclectic  remedies,  such  as  echinacea  and  baptisia. 

Aside  from  the  use  of  proper  antiseptics  and  correctives  from 
the  beginning,  the  diarrhoea  may  properly  be  allowed  to  take  its 
course,  as  general  treatment  will  serve  a  better  purpose  than  local 
measures.  If  any  particular  remedy  were  to  be  recommended,  it 
would  be  a  decoction  of  erigeron  canadense  plant,  a  remedy  that  is 
readily  obtainable  in  the  autumn  season.  This  cannot  do  any  harm, 
and  may  be  drunk  freely. 

TYMPANITES. — Extreme  distension  of  the  abdomen  may  seem  to 
demand  special  attention.  With  the  improved  treatment  I  have 
called  attention  to,  there  will  be  but  few  cases  where  it  will  be  prom- 
inent; however,  an  occasional  case  may  demand  attention.  An  old 
and  useless  (as  it  seems  to  me)  practice  consists  of  the  application 
of  turpentine  stupes  to  the  abdomen.  The  room  and  surroundings 
are  thus  filled  with  the  disgusting  fumes  of  turpentine,  that  every- 
body in  the  vicinity  may  recognize  the  fact  that  som  -thing  is  being 
done.  This  may  afford  some  satisfaction,  but  the  utility  of  the 
measure  is  doubtful.  Rectal  injections  of  clysters  containing  asafcet- 
ida  also  have  their  advocates,  and  it  is  possible  that  there  may  be 
more  benefit  derived  from  them.  Intestinal  antiseptics,  adminis- 
tered internally,  as  salol  or  naphthol,  are  more  to  be  commended. 

INTESTINAL   HEMORRHAGE. — The   slight  hemorrhages  of  capillary 


TYPHOID  FEVER.  89 

origin,  and  which  occur  early  in  the  course  of  the  disease,  require 
no  treatment;  but  after  the  second  week  intestinal  changes  may 
have  occurred,  which  will  render  hemorrhage  liable  to  escape  from 
the  arteries  which  supply  the  intestinal  walls,  and  which  will  demand 
prompt  arrest,  when  this  is  possible.  It  does  not  seem  that  there 
will  be  much  danger  of  hemorrhage  when  the  treatment  here  sug- 
gested is  faithfully  followed  throughout  the  early  part  of  the 
disease,  though  it  is  true  that  some  epidemics  are  attended  by  more 
severe  intestinal  lesion  than  others,  and  that  the  condition  of  the 
patient  prior  to  the  attack  may  predispose  him  to  deep  necrotic 
changes  here ;  but  I  have  found  little  reason  to  expect  intestinal 
hemorrhage  of  serious  nature,  in  my  experience. 

A  patient  with  intestinal  hemorrhage  should  be  kept  strictly 
quiet,  and  should  have  decoction  of  erigeron  canadense  administered, 
two.-ounce  doses  every  half  hour,  until  the  active  hemorrhage  is 
arrested.  If  oozing  continues,  the  remedy  may  be  repeated  at  longer 
intervals,  until  the  discharge  is  entirely  arrested.  It  has  been 
advised  to  apply  ice-bags  to  the  abdomen  and  administer  hypoder- 
mic injections  of  ergo  tine.  A  pill  containing  acetate  of  lead,  gr.  ii, 
and  extract  of  opium,  gr.  x,  administered  every  four  hours,  has  been 
known  to  succeed  where  there  was  persistent  oozing. 

The  collapse  which  follows  intestinal  hemorrhage  may  require 
hypodermic  injections  of  strychnia,  these  being  employed  in  fifteenth 
or  thirtieth  of  a  grain  doses,  and  repeated  every  two  hours  until 
reaction  takes  place. 

CONSTIPATION. — In  a  few  cases  constipation  may  be  present,  and 
pressure  may  be  brought  to  bear  to  induce  th^  physician  to  admin- 
ister a  cathartic.  It  would  be  bad  practice,  however,  to  administer 
opening  medicines  to  any  one  affected  with  enteric  fever.  It  would 
be  better  to  allow  the  bowels  to  remain  ten  days  without  an  evacua- 
tion than  to  commit  the  error  of  administering  a  cathartic.  True, 
theie  might  be  some  urgent  symptom  requiring  a  violation  of 
tliis  rul  ,  but  the  danger  of  allowing  ample  time  for  nature  to 
regulate  this  condition  is  not  usually  comparable  with  that  of  forcing 
an  evacuation  with  cathartics.  Mellin's  food  is  an  excellent  article 
of  diet  where  constipation  is  present,  though  the  condition  will 
hardly  arise  unless  pure  milk  is  employed  as  food,  which  should  not 
b;;  allowed  in  any  case. 

Convalescence  is  a  critical  period  in  the  management  of  typhoid 
fever,  as  the  patient  is  prone  to  indulge  in  exercise  and  diet  which 
may  prove  fatal  iu  their  results.  Fatal  peritonitis  may  follow  the 
early  ingestion  of  solid  food,  and  the  patient  should  be  solemnly 
warned  of  the  danger  incurred  by  too  early  indulgence  in  such 


90  SPECIFIC  INFECTIOUS  DISEASES. 

matters.  During  this  period  the  diet  should  be  restricted  to  milk, 
cream,  gruels,  jellies,  and  animal  broths.  Ice-cream,  in  moderate 
quantities,  may  be  permitted,  but  solid  food,  such  as  meats,  vege- 
tables, and  fruits,  should  be  strictly  forbidden. 

As  healing  of  the  intestinal  ulcers  is  not  completed  until  two  or 
three  weeks  of  convalescence  have  passed,  the  patient  should 
remain  in  the  recumbent  position,  part  of  the  time  at  least,  and 
avoid  all  exercise,  except  walking  about  the  sick-room,  during  thai 
time.  The  use  of  solid  food  should  be  begun  with  very  small  quan- 
tities at  a  time. 

SUPPLEMENTAL  THERAPEUTICS. — A  few  other  means  employed  in 
the  treatment  of  this  disease,  are  worthy  of  mention. 

Intestinal  Antisepsis. — Modern  old  school  authorities  regard  this 
with  great  favor,  some  asserting  that  through  it  the  course  of  the 
disease  may  be  aborted.  The  principal  remedies  used  are  salol, 
beta-naphthol,  salicylate  of  bismuth,  creosote,  iodide  of  potassium, 
and  some  other  antiseptic  agents. 

Further  suggestions  on  the  treatment  of  this  disease  may  be 
found  in  "Dynamical  Therapeutics." 

n.    TYPHUS  FEVER. 

Synonyms. — Ship  Fever;  Jail  Fever;  Irish  Ague. 

Definition. — This  is  an  acute,  contagious  disease,  characterized 
by  sudden  and  marked  prostration;  abrupt  invasion  of  fever,  with 
rapid  rise  of  temperature ;  a  peculiar  rash ;  marked  nervous  symptoms; 
and  a  termination  by  crisis,  about  fourteen  days  from  commencement. 

Etiology. — The  poison  of  this  disease  has  not  yet  been  identi- 
fied, but  it  is  probably  similar  to  that  of  other  infectious  diseases, 
viz.,  a  microscopic  germ,  capable  of  producing  the  disease  by  rapid 
multiplication  and  the  generation  of  ptomaines  in  a  healthy  per- 
son, after  entering  the  system,  upon  exposure  to  the  infection. 
Near  approach  to  one  affected  is  usually  a  requisite  to  infection,  and 
the  carrying  of  the  disease  in  clothing,  as  in  small-pox,  is  of  very 
rare  occurrence.  It  rarely  travels  from  house  to  house,  and  is  usu- 
ally communicated  to  those  in  constant  attendance,  instead  of  to 
occasional  visitors,  nurses  and  house-physicians  being  much  more 
likely  to  contract  the  disease  than  the  visiting  physician.  Loomis, 
in  his  work,  "Practical  Medicine,"  relates  that  during  an  epidemic  of 
typhus  fever  which  prevailed  in  New  York,  from  1861  to  1864, 
of  those  who  attended  to  washing  and  packing  away  the  clothing 
of  patients  brought  into  the  hospital,  after  it  had  been  removed 
in  the  reception  room,  all,  even  to  an  individual,  escaped  the  disease, 


TYPHUS  FEVER.  91 

while  every  one  whose  duty  it  was  to  assist  in  carrying  them  from 
the  reception  room  to  the  wards,  took  the  fever. 

It  would  seem,  then,  that  near  approach  to  those  affected  is 
essential  to  the  contagion,  and  that  this  is  modified  much  in  open  air, 
our  author  stating  that  less  than  two  and  a  half  feet  measure  the 
average  limit  of  infective  distance  from  an  affected  person,  under 
such  circumstances. 

While  Loomis  states  that  the  disease  seems  not  readily  prop- 
agated by  fomites  alone,  most  authorities  assert  that  it  can  be  so 
conveyed.  The  hospital  experience  referred  to  in  former  para- 
graphs, however,  appears  to  throw  much  doubt  on  the  statement. 

Only  the  great  seaports  afford  cases  of  this  kind  on  the  American 
continent,  and  these  are  usually  brought  there  by  vessels  entering 
from  foreign  parts.  Europe  seems  to  be  the  geographical  center  of 
origin,  the  disease  being  common  in  Russia,  England,  and  Ireland. 

The  disease  is  most  liable  to  occur  among  those  who  are  occupy- 
ing crowded  quarters,  such  as  old  tenement-houses,  jails,  and  other 
illy  ventilated  public  places.  Owing  to  improved  sanitary  condi- 
tions, typhus  fever  occurs  but  rarely,  in  modern  times. 

A  single  attack  affords  an  individual  immunity  against  subse- 
quent ones. 

Pathology. — The  pathological  lesions  of  the  tissues  and  blood 
found  in  typhus  fever  resemble  those  of  typhoid,  in  many  particulars. 
The  blood  in  typhus  is  found  darker  in  color  than  normal,  and  when 
abstracted  during  life  it  is  seen  to  have  lost  its  normal  property  of 
coagulation;  and,  if  a  clot  forms,  it  is  brittle  and  pultaceous,  the 
mass  seeming  to  be  devoid  of  fibrin  elements.  The  red  corpuscles 
are  increased  in  number  at  first,  but  they  diminish  as  the  disease 
progresses;  there  is  also  a  change  in  the  salts,  the  blood  rapidly 
undergoing  ammoniacal  decomposition  when  drawn  from  the  body. 
Before  standing,  the  blood  contains  urea  and  ammonia  in  excess. 
Microscopic  examination  shows  many  of  the  corpuscles  degenerated, 
broken  up,  their  edges  irregular  and  serrated.  The  coloring  matter 
thus  set  free  stains  the  lining  of  the  bloodvessels,  heart,  and  other 
tissues. 

Enlargement  and  friability  of  the  heart,  lungs,  Uver,  and  kidneys 
are  not  so  marked  usually  as  in  typhoid,  though  the  tendency  to 
cloudy  swelling  and  granular  degeneration  of  the  voluntary  muscles, 
heart,  kidneys,  and  other  internal  organs,  is  present.  Pultaceous 
clots  are  often  found  ra  the  cavities  of  the  heart,  or  adhering  to  the 
walls  of  the  larger  bloodvessels.  Splenization  and  hypostatic  con- 
gestion of  the  lungs,  as  well  as  pulmonary  oedema,  are  common  results 
of  this  disease. 


92  SPECIFIC  INFECTIOUS  DISEASES. 

The  brain  differs  much  from  that  of  typhoid  fever  in  its  post- 
mortem appearance.  The  vessels  are  here  more  or  less  congested, 
and  the  sinuses  and  large  vessels  are  often  engorged  with  blood, 
while  the  brain  of  the  typhoid  fever  patient  presents  an  aueemic 
appearance.  Sometimes — and  this  may  ba  characteristic  of  certain 
epidemrcs  of  typhus — there  maybe  more  or  less  extensive  exudation 
of  serum  into  the  meshes  of  the  pia  mater,  instead  of  marked  con- 
gestion. Sometimes  this  effusion  is  turbid,  suggesting  meningitis 
as  a  complication.  In  these  cases  the  arachnoid  will  be  dotted  over 
with  yellow  or  yellowish-white  spots,  and  its  glistening  appearance 
will  be  lost. 

The  abdominal  lesions  of  typhus  are  not  characteristic,  and  this 
will  serve  to  distinguish  it  from  typhoid,  should  any  confusion  exist. 
There  may  be  congestion  of  the  intestinal  glands,  with  tendency  to 
ulceration,  but  such  a  condition  prevails  more  or  less  in  scarlatina 
and  measles,  and  is  not  distinctive  of  typhus.  The  marked  and  dis- 
tinctive ulceration  which  characterizes  typhoid  is  not  present  in 
typhus  fever. 

Glandular  enlargements  constitute  a  prominent  feature  of  the 
pathology  of  typhus  fever.  The  superficial  cervical  glands,  and  the 
parotid  and  sublingual,  are  often  so  much  swollen  as  to  interfere 
with  deglutition.  This  marked  swelling  may  sometimes  apparently 
be  the  immediate  cause  of  death. 

The  inguinal  glands  are  also  often  swollen,  so  much  as  to  retard 
the  venous  circulation  from  the  lower  extremities,  and  cause  exten- 
sive swelling  of  these  parts.  Sometimes  the  irritation  extends  to  the 
veins,  and  a  condition  resembling  phlegmasia  dolens  results.  Again, 
the  cellular  tissues  may  be  involved  and  suppuration  occur,  resulting 
in  large  abscesses. 

The  special  senses  are  not  so  markedly  involved  as  in  typhoid, 
and  the  digestive  organs  are  not  much  disturbed,  in  the  majority  of 
cases,  vomiting  and  diarrhoea  being  of  comparatively  rare  occurrence. 

Symptoms. — INCUBATION. — This  may  last  from  a  few  hours  to 
two  weeks.  During  this  time  there  may  be  ill-defined  sensations  of 
discomfort,  with  dull  headache,  loss  of  appetite,  fugitive  pains,  and 
other  premonitory  symptoms;  but  such  indications  are  usually 
absent,  the  onset  being  unannounced. 

INVASION. — The  sta^e  of  invasion  is  abrupt.  Premonitory  symp- 
toms, such  as  malaise,  headache,  insomnia  with  restlessness  at 
night,  nausea,  anorexia,  etc.,  may  mark  a  few  days  of  the  latter  portion 
of  the  period  <  f  incubation,  but  often  the  first  symptom  is  a  decided 
chill,  \\hich  is  short,  sharp,  and  sudden;  this  is  followed  by  fever, 
with  rapid  rise  of  temperature.  Sometimes  the  chill  is  not  marked, 
and  only  slight  chilly  sensations  announce  the  onset.  Following 


TYPHUS  FEVER  93 

the  chill  is  a  marked  headache,  which  steadily  increases  in  severity. 
It  involves  the  frontal  region,  and  soon  becomes  intense.  Severe 
pains  in  the  back  and  limbs  attend,  and  as  febrile  symptoms,  with  a 
rapidly  rising  temperature,  come  on,  a  sense  of  extreme  prostration 
overpowers  the  patient.  Loomis  relates  that  at  one  time,  while  he 
was  making  his  visits  in  a  typhus  fever  ward,  his  house  physician, 
who  had  contracted  the  disease,  staggered  and  fell  at  his  side  while 
accompanying  him,  and  died  on  the  eighth  day.  Though  loss  of 
muscular  power  is  not  usually  so  sudden,  the  patient  will  be  com- 
pelled to  take  his  bed  witiiin  twenty-four  hours,  and  the  attending 
prostration  is  more  marked  early  than  in  any  other  febrile  disease. 
Soon,  in  the  majority  of  cases,  the  patient  becomes  so  weak  as  to  be 
unable  to  turn  in  bed,  and  lies  helpless  on  his  back  Paralysis  of 
the  sphincters  soon  attends,  with  involuntary  evacuation  of  urine  and 
feces.  Dysphagia,  partial  aphonia,  and  inability  to  protrude  the 
tongue,  are  often  present.  Muscular  tremors,  subsultus  tendinum, 
picking  at  the  bedclothes,  hiccough,  strabismus,  and  opisthotonos, 
may  occur  in  desperate  oases. 

The  fever  may  run  a  typical  course,  the  stadium  being  reached  in 
many  cases  as  early  as  the  third  day.  However,  this  stage  may 
not  be  attained  unt.l  two  or  three  days  later.  The  regularity  with 
which  typhoid  fever  advances  during  the  first  week  is  not  observed 
in  this  form,  and  a  record  of  the  temperature  during  the  first  few 
days  would  not  be  much  assistance  in  diagnosis. 

TEMPERATURE. — Though  chilly  symptoms  may  persist  for  two  or 
three  days,  the  temperature  rises  rapidly,  and  within  the  first  twenty- 
four  hours  may  reach  105°  or  106D  F.  In  other  cases,  two  or  three 
days  may  be  occupied  in  the  development  of  the  fastigium.  The 
morning  and  evening  variations  are  most  marked  at  midnight,  but 
these  are  not  regular  as  in  typhoid,  there  hardly  being  a  regular 
periodicity,  and  the  crisis  occurs  without  any  increase  in  the  length 
or  degree  of  the  diurnal  variation.  Sometimes,  on  the  day  pre- 
ceding the  crisis,  the  temperature  rises  three  or  four  degrees  higher 
thau  before.  The  temperature  usually  ranges  the  highest  during 
the  second  week. 

The  headache  of  typhus  is  a  notable  feature,  appearing  early,  and 
steadily  increasing  in  severity  for  the  first  week.  Associated  with 
this  is  dullness  and  confusion  of  intellect,  sometimes  vomiting.  It 
is  said  that  the  headache  of  typhus  is  much  more  constant  and 
severe  thau  that  of  any  other  fever. 

The  pulse  is  rapid  and  full  in  the  beginning,  but  it  soon  becomes 
feeble,  soft,  and  compressible,  and  increased  in  frequency.  In 
unfavorable  cases,  when  a  fatal  termination  is  nearing,  it  becomes 


94 


SPECIFIC  INFECTIOUS  DISEASES. 


dicrotic,  irregular,  and  intermitting.  The  tongue  is  swollen  at  first, 
ami  covered  with  a  white  coating,  but  in  a  few  days  it  becomes 
brown,  and,  later,  black,  dry,  and  fissured.  In  severe  cases,  the 
tongue  is  shrunken,  and  rolled  in  a  ball,  at  the  back  of  the  mouth. 

The  countenance  presents  a  peculiar  appearance,  the  face  being 
darkly  flushed,  and  the  expression  dull  and  weary,  the  cheeks  often 
being  of  mahogany  color.  The  sleep  is  restless  and  disturbed,  and, 
when  the  patient  is  awake,  his  mind  does  not  seem  clear,  even  in 
the  early  part  of  the  disease. 

Delirium  of  pronounced  character  comes  on  about  the  eighth 
day,  though  it  may  be  present  much  earlier,  and  the  headache,  which 
has  been  such  an  unpleasant  feature,  now  subsides.  It  is  more 
marked  at  night,  at  first,  usually  passing  off  in  the  morning,  to 
return  at  night;  but  it  soon  becomes  continuous,  varying,  in  different 


DAY 

or 

DttEASC 


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106° 

1CS° 
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100 

99 

98 


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Iff  11 


V 


12 13 14 15  till 


TEMPEKATCBE  IN  A  CASE  OF  TYPHCB  FEVEB. 


patients,  from  a  low  muttering,  to  the  most  active  and  noisy  kind. 
Loomis  asserts  that  acute  delirium  is  most  apt  to  be  present  when 
the  patient  is  intelligent  and  highly  cultured,  and  that  of  muttering 
character  in  aged  persons,  or  those  of  little  culture.  Stupor  or  som- 
nolence follows  the  period  of  delirium,  the  patient  lying  in  a  condi- 
tion of  coma  vigil,  for  hours  before  death.  Favorable  cases  are 
more  apt  to  be  marked  by  somnolence,  prior  to  the  period  of  crisis. 
The  rash  of  typhus  fever  appears  from  the  fifth  to  the  eighth 
day  of  the  disease,  usually  on  the  fifth.  It  consists  at  first  of  dirty 
pink  spots,  which  appear  on  the  abdomen  and  gradually  extend 
over  the  body,  showing  everywhere  except  on  the  face  and  palms 
of  the  hands.  These  spots  vary  in  size,  from  mere  points  to  three 


TYPHUS  FEVER.  95 

or  four  lines  in  diameter,  are  slightly  elevated,  and  disappear  on 
firm  pressure.  In  a  day  or  two  the  eruption  becomes  much  darker, 
of  purplish,  mulberry  color,  the  elevation  subsides,  and  the  spots 
remain  uader  pressure. 

Diagnosis. — It  is  not  difficult  to  distinguish  typhus  from  other 
diseases  which  it  may  sometimes  resemble,  if  it  be  recollected  that 
it  is  a  contagious  disease,  confined  to  its  immediate  surroundings. 
While  it  may  resemble  typhoid  fever  in  some  of  its  characteristics, 
it  must  be  remembered  that  the  invasion  of  typhoid  is  very  gradual 
usually,  while  this  is  sudden  in  its  onset.  The  abdominal  symptoms 
of  typhoid  are  also  characteristic,  while  tympanites  and  tenderness 
on  pressure  are  absent  in  typhus,  and  diarrhoea  is  hardly  ever 
present.  The  rash,  on  the  fifth  day,  is  entirely  different  in  appear- 
ance from  that  of  typhoid,  which  appears  later. 

The  duration  of  typhus  fever  is  also  a  distinctive  feature,  the 
disease  terminating  by  the  fourteenth  day,  while  few  ca^-es  of  typhoid, 
aud  no  severe  ones,  terminate  within  three  weeks.  Cerebro-spinal 
fever  resembles  typhus  in  some  cases,  but  the  rash  is  different  in 
character  and  the  temperature  is  lower,  hardly  ever  rising  over  102° 
or  103°  F.,  and  the  disease  runs  a  much  more  protracted  course,  in 
most  cases.  Where  there  is  meningeal  inflammation  in  typhus, 
there  are  many  symptoms  in  common  with  this  disease,  such  as  the 
intense  headache,  delirium,  rigidity  of  the  muscles,  etc.  Only  those 
practicing  in  seaport  towns  need  take  the  trouble  to  exclude  typhus 
from  a  doubtful  diagnosis,  as  the  disease  seldom  or  never  penetrates 
to  the  interior,  in  this  country. 

Prognosis. — This  is,  without  doubt,  a  dangerous  disease,  and 
one  which  is  liable  to  result  fatally,  with  the  best  of  treatment. 
Unfortunately,  Eclectic  methods  have  never  been  thoroughly  tiied, 
so  that  no  estimate  from  such  a  standpoint  can  be  made.  Those 
conversant  with  the  disease  and  the  results  of  treatment,  vary  in 
estimating  the  deaths  from  one  in  five  to  one  in  sixteen  of  the  cases 
affected,  in  different  epidemics.  The  mortality  seems  to  vary  at 
different  times,  some  epidemics  being  much  more  severe  than  others. 
The  surroundings  of  the  patient  certainly  exert  much  influence  upon 
the  disease,  pure  air  and  other  favorable  influences  encouraging  a 
successful  issue.  When  the  patient  is  debilitated  in  the  start,  has 
been  addicted  to  alcoholism,  or  is  the  subject  of  gouty  diathesis, 
his  chances  of  recovery  are  diminished.  Overcrowding  or  bad  ven- 
tilation are  opposed  to  favorable  results.  Complications  are  often 
the  causa  of  death,  such  as  cerebral  or  pulmonary  congestion,  and 
some  one  of  these  complications  may  be  a  peculiar  feature  of  each 
epidemic;  and  as  this  is  marked,  so  the  mortality  is  liable  to  be 


96  SPECIFIC  INFECTIOUS  DISEASES. 

increased.  The  prognosis  is  less  grave,  when  the  disease  occurs  in 
childhood. 

Treatment. — Evidently,  from  what  old  school  authorities  assert, 
there  is  little  to  be  expected  from  treatment;  that  is,  from  the  action 
of  medicines.  Loomis  asserts  that  fresh  air  is  the  only  thing  which 
will  neutralize  the  poison  of  this  disease.  He  advises  placing  the 
patient  in  a  tent  or  open  pavilion  so  that  the  air  can  circulate  freely 
around  him,  covering  him  with  blankets,  if  the  air  be  chilly.  He 
asserts  that  he  has  seen  patients — apparently  overwhelmed  by  the 
fever  poison,  so  much  as  to  be  in  a  state  of  coma  with  high  tempera- 
ture, and  apparently  rapidly  succumbing  to  the  disease — brought 
from  crowded  tenement  houses  and  placed  in  tents,  begin  to  rally 
within  four  or  five  hours,  and  go  on  to  speedy  recovery.  This 
author  places  more  stress  upon  such  plan  of  treatment  than  upon 
any  drugs  that  may  be  employed.  The  same  writer  deprecates  the  use 
of  alcohol  as  a  stimulant,  averring  that,  though  it  may  seem  to  bene- 
fit at  first,  it  is  liable  to  finally  arrest  secretion,  prevent  the  elimina- 
tion of  urea,  and  disturb  nutrition,  thus  lessening  the  chances  of 
recovery.  He  indorses  the  employment  of  opiates  to  induce  sleep, 
asserting  that  the  protracted  insomnia  is  of  itse  If  sufficient  to  cause 
a  fatal  termination.  To  reduce  the  temperature,  he  recommends  cold 
baths  and  quinine  as  antipyretics  during  the  last  week,  and  urges 
the  importance  of  proper  feeding,  stating  that  the  patient  must  be 
required,  and  even  compelled,  to  take  nourishment,  advising  the  plan, 
should  he  refuse  to  take  it  without,  of  pouring  liquids  down  through 
a  rubber  tube  passed  into  the  stomach,  by  way  of  the  nose, 
when  the  patient  clinches  his  teeth  and  refuses  to  receive  it.  Milk, 
malted  milk,  Horlick's  food,  etc.,  will  answer  the  purpose,  and  some 
should  be  given  regularly  and  at  frequent  intervals,  as  iu  the  treat- 
ment of  typhoid  fever.  During  convalescence,  care  should  be  taken 
that  tho  patient  be  not  exposed  to  sudden  changes  of  temperature  so 
as  to  take  cold,  or  permitted  to  overexert  himself  (as  this  might 
result  in  coagulation  of  blood  in  the  veins)  until  after  the  blood  has 
been  restored  to  a  normal  condition.  Moderate  exercise  in  the  open 
air  is  commendable.  Convalescence  is  usually  rapid. 

I  am  of  the  opinion  that  this  disease  could  be  much  modified  by 
the  action  of  echinacea.  I  have  treated  a  few  cases  that  I  diag- 
nosed as  typhus  fever  at  the  time,  which  I  am  now  convinced  were 
cases  of  cerebro-spinal  fever;  but  from  the  close  resemblance,  and 
the  excellent  action  of  echinacea  in  these  cases,  I  would  expect  good 
results  from  it  in  fyphuoj  and  salicylate  of  ammonium  ought  to 
reduce  the  temperature  and  lessen  the  tendency  to  blood  depravation. 

Should  the  opportunity  arise,  I  hope  that  some  of  our  Eclectic 


KELAPSING  FEVER.  97 

physicians  will  test  these  remedies  in  this  disease  and  report  results 
to  our  medical  journals.  Doubtless,  the  antipyretic  influence  of  jab- 
orandi  and  other  vascular  sedatives,  cold  packs,  baths,  etc.,  will 
ameliorate  the  severity  of  the  symptoms,  lower  the  maximum  tem- 
perature, and  assist  in  preserving  vital  structures  against  destruc- 
tive action. 

III.  RELAPSING  FEVER. 

Synonyms. — Spirillum  Fever;  Famine  Fever;  Hungerpest. 
Definition. — An  acute,  contagious  febrile  disease,  characterized 
by  two  paroxysms  of  high  fever  of  from  five  to  seven  days  each, 
with  an  intermission  between,  of  from  three  to  five  days'  duration. 
Etiology. — When  relapsing  fever  occurs  in  this  country,  it  is 
the  result  of  importation  from  Europe.  This  is  of  rare  occurrence, 
so  much  so  that  the  disease  has  not  been  deemed  worthy  of  mention 
by  all  American  authorities  on  practice.  The  disease  occurred  as 
an  epidemic  in  New  York  City,  in  1872-3,  and  in  Philadelphia,  in 
1844.  In  both  instances,  it  was  brought  from  Europe  by  emigrants. 
It  is  highly  contagious,  and  within  a  few  years  past  bacteriologists 
have  asserted  that  the  producing  factor  is  a  parasitic  organism — the 
spirittum  Obermaieri.  It  has  been  called  "famine  fever,"  but  those 
who  are  well  fed  are  as  susceptible  to  the  contagion  as  others.  Bad 
water  and  food,  overcrowding,  and  vitiated  air,  predispose  to  epi- 
demics. The  disease  is  not  likely  to  be  carried  on  clothing,  and  is 
seldom  communicated  except  by  direct  transmission. 

The  spirillum  of  relapsing  fever  (spirochaete  of  Obermaier)  is  a 
narrow  spiral  filament,  which  measures  from  three  to  six  times  the 

diameter  of  a  red  corpuscle  in  length,  and 
is  readily  seen  moving    about    among    the 
blood-disks  during  the  paroxysms — the  only 
periods  in  which  they  are  visible.     Shortly 
before  the  crisis  and  during  the  intermission 
they  are  not  found,  though  small,  glistening 
bodies,    supposed    to   be   spores,   are    then 
detectable.      During  the  paroxysms,  inocu- 
or  *£<-A^ "^ion  of  a  healthy  person  with  the  blood  of 
'"'  an  affected   subject  will  propagate  the  dis- 
ease.    It  is  also  communicable  to  monkeys,  in  the  same  way. 

Pathology. — There  are  no  lesions  characteristic  of  this  disease 
alone,  the  parenchymatous  changes  due  to  febrile  action  appearing 
here  in  proportion  to  the  severity  of  the  disease,  as  elsewhere. 
The  liver  and  spleen  are  enlarged,  the  spleen  frequently  being  the 


1)8  SPECIFIC  INFECTIOUS  DISEASES. 

seat  of  infarctions.  The  cortical  substance  of  the  kidneys  is  con- 
gested, and  the  bulk  of  the  organs  thus  increased,  while  granular 
infiltration  of  the  uriniferous  tubules,  similar  to  that  noticed  in 
other  fevers,  may  be  noticed.  In  some  cases,  extravasations  of 
blood  are  found  distributed  throughout  the  organ.  Extravations  of 
blood  may  also  be  found  upon  the  mucous  membranes,  especially 
of  the  intestines,  stomach,  and  bronchial  tubes.  The  blood  coagulates 
imperfectly,  as  in  typhus  fever,  though  coagula  in  the  blood-vessels 
are  rare. 

Symptoms. — INCUBATION. — This  period  may  be  short,  lasting 
only  a  few  hours  in  some  cases,  though  it  is  usually  of  six  or  eight 
days'  duration.  During  this  time  there  are  not  often  any  symptoms 
to  suggest  the  coming  onset. 

INVASION. — This  is  usually  abrupt,  a  pronounced  chill  announcing 
the  commencement  of  the  attack.  This  is  attended  by  frontal  head- 
ache of  excruciating  character,  severe  pains  in  the  muscles  of  the 
limbs  and  back,  nausea,  and  vomiting.  The  temperature  rises  rap- 
idly, usually  reaching  its  highest  point  within  twenty-four  hours  after 
the  initiation  of  the  disease.  It  may  rise  as  high  as  104°  or  106°, 
and,  in  some  cases,  as  high  as  109°  F. 

The  pulse  increases  in  frequency  very  rapidly,  and  this  disease 
is  remarkable  for  the  rapidity  which  the  pulse  reaches  140,  150,  or 
160  beats  per  minute  within  the  first  twenty-four  hours.  It  is  small 
and  compressible,  usually,  sometimes  dicrotic. 

Delirium  is  not  a  common  symptom,  the  patient  generally  retain- 
ing control  of  his  mental  faculties  throughout,  though  sleepless- 
ness is  a  common  condition,  on  account  of  the  severity  of  the 
muscular  pains.  The  pains  may  affect  the  joints  particularly,  and 
may  become  the  most  unpleasant  part  of  the  disease. 

As  the  liver  and  spleen  become  involved — by  the  second  day — 
weight  and  uneasiness  in  the  upper  portion  of  the  abdomen,  espe- 
cially in  the  hypochondrium,  will  be  noticed,  while  enlargement  and 
tenderness  of  both  liver  and  spleen  will  be  found  upon  palpation. 
Jaundice  develops  in  many  cases,  and  this  may  be  accompanied  by 
vomiting  and  diarrhoea. 

Marked  prostration,  irregularities  of  the  pupils,  soreness  and 
stiffness  of  the  muscles  of  the  eyes,  etc ,  are  other  features.  By  the 
sixth  or  seventh  day  the  febrile  symptoms  have  become  aggravated 
to  their  fullest  extent;  the  pulse  Is  150  or  160  per  minute,  the 
tongue  is  dry  and  brown,  the  muscular  pains  are  excruciating,  and 
emaciation  has  begun  to  be  marked,  while  the  prostration  is  extreme, 
it  seeming  that  a  fatal  issue  must  be  near  at  hand.  Now,  a  sudden 
remission  occurs,  profuse  perspiration  breaks  out  on  the  surface, 


RELAPSING  FEVER. 


99 


secretion  becomes  established  from  the  kidneys,  the  headache  and 
pains  subside,  sometimes  a  critical  diarrhoea  occurs,  and  the  pulse 
rapidly  falls  to  80  or  90  beats  per  minute,  while  the  temperature 
becomes  normal  within  twelve  hours  from  the  first  appearance  of 
subsidence.  Then,  barring  a  sense  of  weakness,  the  patient  feels 
perfectly  well.  His  appetite  begins  to  return,  he  gets  out  of  bed, 
and  appears  to  be  rapidly  convalescing.  His  pulse  will  now  be  found 
to  be  slower  than  normal,  and  his  temperature  normal,  or  near  there. 
But  this  period  of  comfort  is  of  short  duration.  In  a  few  days  (three 
or  four,  sometimes  a  week)  the  attack  is  repeated,  with  more  sever- 
ity than  before. 


DAY 

OF 

D/SfASf 


1 


tor' 

toe' 

JOS 

104' 
103' 


77 


10 


93 


TEMPERATURE  IN  A  CASE  OF  RELAPSING  FEVER. 

The  headache,  the  arthritic  and  muscular  pains,  the  high  tempera- 
ture, and  the  rapid  pulse,  are  again  ushered  in  with  great  rapidity, 
sometimes  with  and  sometimes  without  a  chill,  and  the  hepatic  and 
splenic  congestion  again  occurs.  This  continues  from  two  days  to  a 
week,  when  a  second  crisis  occurs,  similar  to  the  former  one,  and 
within  twenty-four  hours  from  commencement  the  pulse  and  tem- 
perature have  reached  normal,  and  the  unpleasant  symptoms  have 
again  subsided.  This  time,  usually,  the  convalescence  is  real,  and 
the  patient  goes  on  to  complete  recovery,  though  in  some  cases  three 
or  four  relapses  may  occur. 

Some  of  the  complications  of  relapsing  fever  are  pneumonia,  col- 
lapse, ophthalmia,  diarrhoaa,  and  dysentery. 

Diagnosis. — After  the  disease  has  been  established,  the  diag- 


100  SPECIFIC  INFECTIOUS  DISEASES. 

nosis  is  not  difficult,  its  contagious  character,  the  distinct  intermis- 
sion after  several  days  of  fever,  the  severe  headache,  and  the  ar- 
thritic pains,  will  afford  a  correct  picture  of  the  disease.  Dengue 
fever,  though  it  resembles  this  disease  in  many  particulars,  is  char- 
acterized by  an  eruption,  which  appears  during  the  second  parox- 
ysm, and  the  remission  does  not  amount  to  an  intermission,  as  in 
relapsing  fever.  In  typhus,  the  headache  is  almost  invariably  suc- 
ceeded by  delirium  by  the  beginning  of  the  second  week,  while  delir- 
ium is  not  common  in  this  disease.  The  intermission  occurring  by 
or  before  the  end  of  the  first  week  will  also  settle  the  question  of 
typhus.  The  slow  invasion  of  typhoid  fever  will  distinguish  it  from 
relapsing  fever,  in  which  the  invasion  is  accomplished  within  twenty- 
four  hours  after  the  onset.  Abdominal  symptoms  are  also  a  marked 
feature  of  typhoid,  while  they  are  not  present  here.  The  history  of 
the  case  will  suggest,  to  the  American  practitioner,  a  foreign  origin 
for  the  disease.  Cerebro-spinal  fever  is  marked  by  severe  head- 
ache and  muscular  pain,  but  the  temperature  is  usually  low,  as  com- 
pared with  that  of  relapsing  fever,  and  is  very  irregular — if  high  one 
day  it  is  liable  to  be  low  another,  and  is  not  to  be  relied  upon  to  fol- 
low any  regular  course. 

Prognosis. — The  prognosis  in  relapsing  fever  is  very  favorable, 
notwithstanding  the  severe  ordeal  through  which  the  patient  passes. 
Though  a  disease  attended  by  much  suffering,  it  does  not  seem  as 
inimical  to  life  as  some  diseases  of  apparently  milder  character. 
Loomis  estimates  that  only  about  three  per  cent  of  all  the  cases 
treated  in  the  hospitals  of  New  York,  during  the  epidemic  referred  to 
in  this  article,  died.  Syncope  and  other  complications,  such  as 
bronchitis,  pneumonia,  diarrhoea,  dysentery,  and  ursemia  from  renal 
congestion,  supply  the  greatest  mortality.  Aged  and  feeble  persons 
may  die  from  collapse  during  the  crisis,  though  this  is  not  likely  to 
occur. 

Treatment. — The  Eclectic  portion  of  the  profession  has  had 
no  opportunity  to  test  the  value  of  their  methods  of  treatment  in 
this  disease.  It  is  asserted  by  those  who  have  had  extensive  expe- 
rience with  it  that  quinine  is  of  no  service  in  its  management.  It  is 
also  asserted  that  aconite,  arsenic,  and  veratrum  have  been  tried  as 
antipyretics,  without  avail.  Cold  baths  have  been  resorted  to  with 
as  little  profit.  It  is  asserted  that  opiates  have  relieved  the  severe 
pain,  and  given  better  satisfaction  than  other  methods  of  treatment. 
Free  ventilation  should  be  given  the  rooms  of  patients  under  treat- 
ment with  this  disease,  without  doubt 

It  seems  that  jaborandi  or  salicylate  of  ammonium  ought  to  lessen 
the  maximum  temperature  of  this  disease,  and,  at  the  same  time, 


CEREBRO-SPINAL  FEVER.  101 

assist  in  controlling  the  severe  headache  and  pain.  A  decoction  of 
rhamnus  californica  ought  also  to  assist  in  relieving  the  intensity  of 
the  pain,  if  not  in  banishing  it  altogether. 

Complications  should  be  treated  as  they  arise,  according  to  mod- 
ern Eclectic  methods.  A  liquid  diet  should  be  employed  throughout 
the  disease,  and  hygienic  methods  of  management  strictly  observed. 

Of  course  we  will  not  lose  sight  of  the  proper  precautions  neces- 
sary to  counteract  any  tendency  to  blood  depravation  which  may  be 
manifested  by  the  condition  of  the  tongue.  The  proper  correctives 
are  well  known  to  all  modern  graduates  of  our  schools,  and  need  not 
be  mentioned  here.  During  convalescence,  cactus  graudiflorus, 
cereus  bonplandii,  or  digitalis  may  be  administered  for  the  tendency 
to  heart  failure ;  and  this  may  be  necessary,  during  the  first  remission. 


IV.  CEREBRO-SPINAL  FEVER. 

Synonyms. — Cerebro- spinal  Meningitis;  Spotted  Fever ;  Pete- 
chial  Fever;  Malignant  Purpuric  Fever. 

Definition. — An  acute,  infectious  disease,  characterized  by 
inflammation  of  the  oerebro-spinal  meninges;  excruciating  pain  in 
the  head,  back,  and  limbs;  irregular  fever;  and  often  by  convulsions 
or  opisthotonos,  and  a  petechial  rash. 

Historical  Note. — This  disease  was  first  identified  in  Geneva, 
in  the  early  part  of  the  present  century.  Soon  afterward  (1806)  it 
appeared  in  Massachusetts,  and  has  since  visited  almost  every  part 
of  the  United  States  and  Canadas. 

Etiology. — The  exciting  cause  of  this  fever  is  yet  a  question. 
It  may  occur  epidemically  or  sporadically,  but  is  most  liable  to  occur 
as  an  epidemic.  All  ages  are  subject  to  it,  but  young  persons  and 
children  are  most  liable  to  attacks.  Bad  hygienic  surroundings  are 
predisposing  causes,  overcrowding,  bad  ventilation,  insufficient  or 
unwholesome  food,  dampness,  etc.,  being  supposed  adjuncts. 

Recent  investigations  have  resulted  in  the  conclusion  that  the 
exudate  invariably  contains  a  lance-shaped  coccus,  identical  with 
the  diplococcus  of  pneumonia,  and  the  constant  presence  of  this 
bacterium  suggests  it  as  the  exciting  cause. 

It  is  not  considered  contagious,  either  directly  or  through  fomites, 
though  crowding  of  communities  together,  as  in  garrisons  and  bar- 
racks, seems  to  predispose  to  outbreaks. 

Pathology. — The  pathology  of  this  disease  indicates  two  forms 
of  cerebro-spinal  meningitis.  The  first  to  be  mentioned  is  the 
sporadic  form,  where  the  anatomical  lesions  are  confined  to  evidences 
of  simple  inflammation  of  the  meniuges  of  the  brain  and  spinal 


102  SPECIFIC  INFECTIOUS  DISEASES. 

cord,  the  second  or  epidemic  form  being  characterized  by  evidences 
of  grave  visceral  and  sanguineous  changee,  akin  to  those  of  typhus, 
typhoid,  and  other  putrid  fevers.  The  brain  is  always  found  more 
or  less  involved,  the  dura  mater  being  tense  and  shining,  and  the 
surface,  especially  at  the  convexity  and  base,  studded  with  punctate 
points  of  extravasation.  Hypersemia  of  the  pla  mater  is  also  a 
constant  condition,  the  vessels  usually  being  injected,  and  the  sur- 
face roughened,  this  condition  involving  both  the  brain  and  spinal 
cord.  The  sinuses  of  the  dura  mater  may  contain  much  softly 
coagulated  blood,  especially  in  the  epidemic  form  of  the  disease,  and 
extensive  exudation  of  sero-fibrinous  or  sero-purulent  fluid  is  found 
over  both  the  convexity  and  base  of  the  brain.  In  the  latter  situa- 
tion, the  cranial  nerves  are  often  imbedded  in  this  substance.  The 
amount  and  color  of  this  exudation  vary,  it  sometimes  presenting  a 
whitish,  soft  appearance,  and  being  in  small  quantity,  while  again  it  is 
abundant,  and  yellowish  or  greenish  in  appearance,  suggesting  puru- 
lency.  This  condition  may  involve  the  posterior  surface  of  the  cord, 
a  purulent  fluid  being  found  under  the  arachnoid.  The  blood  is 
dark  and  tarry  in  appearance  in  the  epidemic  form,  the  fibrin  dimin- 
ished, the  white  corpuscles  increased,  the  fluid  rapidly  decomposing 
when  exposed  to  the  air.  The  muscles  are  dark  colored,  and  the 
tissues  generally  have  undergone  granular  degeneration.  There  is 
often  congestion  of  the  lungs,  liver,  and  spleen,  the  parts  being 
enlarged  and  increased  in  friability.  The  skin  is  frequently  the 
seat  of  an  eruption,  of  petechial  spots,  though  there  is  no  regular 
time  for  its  appearance.  After  death,  purple  or  purpuric  spots 
appear,  especially  along  the  region  of  the  spine ;  and  these  are  often 
present  during  life,  in  certain  epidemics. 

Symptoms. — The  symptoms  of  this  disease  are  of  wide  diver- 
sity of  character,  though  there  are  a  few — such  as  severe  headache 
and  pain  in  the  back  and  extremities — which  are  invariable.  The 
pain  is  notably  severe  in  the  upper  portion  of  the  spine,  the  head 
being  thrown  backward  to  relieve  the  tension  on  the  ligamenturn 
nuchsB  early  in  the  onset,  the  suffering  here  being  described  as 
excruciating.  The  length  of  the  period  of  incubation  is  not  known. 

INVASION. — In  some  cases  the  invasion  of  the  disease  is  abrupt, 
the  patient  being  seized  with  a  chill  and  loss  of  consciousness,  while 
coma,  convulsions,  and  death,  may  follow  within  a  few  hours.  But 
these  are  the  extreme  cases  in  the  epidemic  form.  When  the  disease 
is  sporadic,  the  symptoms  are  more  gradual  in  their  advance,  and 
the  chill  is  not  so  apt  to  be  pronounced,  though  the  patient  may  com- 
plain of  chilly  symptoms  for  several  days.  The  reaction  is  slight, 
the  temperature  not  rising  much  above  normal.  The  headache  and 


CEREBRO-SPINAL  FEVER,  103 

pain  along  the  spine  however  will  be  marked,  the  patient  will  be 
restless  and  sleepless,  and  there  will  be  loss  of  flesh  aud  emaciation, 
as  the  case  progresses.  Often  the  pupils  will  be  found  of  unequal 
size,  while  the  features  present  a  fixed  or  staring  expression.  The 
vase-motor  supply  to  the  face  will  be  involved  early,  and  irregular 
control  of  the  blood-vessels  will  give  rise  to  variability  in  the  appear- 
ance of  the  face,,  it  being  brightly  flushed  or  presenting  a  hectio 
appearance  at  times,  and  within  a  few  minutes  afterward  showing 
a  ghastly  pallor,  especially  after  the  patient  has  become  prostrated 
and  debilitated.  This  irregularity  in  the  circulation  of  the  face  is  a 
notable  feature,  in  the  protracted  form  of  this  disease. 

In  two  or  three  days,  sometimes  later,  delirium  comes  on.  This 
varies  widely  in  character,  sometimes  being  wild  and  violent,  and  at 
other  times  mild  and  muttering.  In  the  slow  form  this  may  not 
appear,  however,  until  several  days  later.  Sometimes  it  is  of  a 
maudlin  character,  resembling  the  vagaries  of  a  drunken  person,  and 
in  women,  it  may  resemble  hysteria.  I  recollect  a  case  treated  a  few 
years  ago,  in  which  the  patient,  a  married  woman  of  about  thirty, 
resisted  my  attempts  to  inspect  her  tongue  during  the  first  visit, 
cried  peevishly  when  disturbed,  and  acted  so  childishly  that  I  sup- 
posed her  husband,  toward  whom  she  manifested  the  same  disposi- 
tion, had  crossed  her  in  some  way,  and  that  she  was  working  off  a  fit 
of  sulks,  though  he  assured  me  that  this  was  not  the  case.  Within 
twenty-four  hours,  however,  there  were  retraction  of  the  head,  irregu- 
larity of  the  pupils,  opisthotonos,  and  tonic  spasms  of  the  extremi- 
ties, with  coma.  Hemiplegia,  followed  by  death,  resulted  within 
ten  days  from  the  time  I  was  first  called.  In  this  case  the  tempera- 
ture was  normal  most  of  the  time,  and  never  above  102°  F.,  the 
extremities  being  cold  continually. 

In  other  cases  the  delirium  is  of  the  most  restless  character,  and 
the  patient  will  make  violent  efforts  to  leave  the  bed,  requiring  an 
attendant  at  his  side  constantly.  In  one  case,  that  of  a  little  boy, 
the  patient  struggled  to  get  out  of  bed,  shrieked,  at  times,  and  tore 
the  Lair  out  of  his  head,  before  his  mother  (who  took  great  pride 
in  his  curls)  could  be  induced  to  cut  it  short.  "With  the  majority 
of  infants  there  is  constant  restlessness  and  insomnia,  there  seem- 
ing to  be  intense  and  persistent  suffering  (as  there  undoubtedly  is), 
and  this  is  evidently  aggravated  by  moving  or  lifting  the  patient. 
Hypercesthesia  of  the  ekin  and  muscles  is  so  marked  that  the  least 
touch  or  pressure  often  elicits  complaint,  and  when  a  child  retains 
its  consciousness,  it  will  cry  in  anticipation,  when  preparations  are 
being  made  to  move  it. 

There  are  many  grades  of  symptoms  in  this  disease,  the  spasmodic 


104  SPECIFIC  INFECTIOUS  DISEASES. 

action  of  the  muscles  coming  on  early  in  some  cases,  and  not  appear- 
ing for  several  weeks,  in  others.  Some  observers  have  divided  the 
cases  into  the  slow  and  rapid  forms.  I  once  witnessed  an  epidemic 
where  children  were  the  ones  principally  affected  (the  disease  follow- 
ing measles),  in  which  a  little  patient  would  roll  its  head,  fret,  aud 
moan,  without  intermission,  five  or  six  weeks,  waste  away,  and  finally 
die  in  a  state  of  marasmus,  apparently  suffering  intense  pain  at  the 
base  of  the  brain,  one  hand  keeping  a  constant  motion  backward  and 
forward  about  the  mastoid  process  for  days  and  nights  at  a  time, 
the  suffering  being  much  increased  whenever  the  child  was  lifted  or 
moved.  During  this  epidemic,  some  rapid  cases  developed,  and 
patients  died  in  convulsions  and  coma  within  a  few  hours  after  the 
onset.  The  disease  was  ushered  in  usually  like  a  remittent  fever 
(sometimes  with  symptoms  of  cholera  infantum),  but  the  means  com- 
monly employed  to  interrupt  the  paroxysms  in  that  disease  produced 
only  temporary  effect  in  these  cases,  relapses  soon  following. 

The  rapid  form  of  the  disease  usually  prevails  during  an 
epidemic,  if  at  all,  while  sporadic  cases  are  usually  of  the  slow  form. 
On  account  of  the  typhoid  symptoms  which  attend,  many  physicians 
have  been  in  the  habit  of  confounding  it  with  typhoid  fever ;  but  there 
is  no  analogy  between  that  disease  and  this.  There  are  no  abdominal 
symptoms,  and  there  is  not  the  regularity  about  the  temperature,  as 
in  typhoid. 

In  sporadic  cases  occurring  in  this  country,  there  is  not  a  very 
marked  change  in  the  appearance  of  the  tongue,  except  during  the 
late  period  of  severe  cases,  it  then  becoming  pinched,  dry,  and  brown. 
Usually,  there  is  a  remarkable  absence  of  disturbance  of  the  alimen- 
tary canal.  The  tongue  is  not  much  altered  in  appearance,  there  is 
no  gastric  irritability,  and  the  bowels  are  not  disturbed;  though 
there  may  be  slight  constipation,  but  not  more  than  might  result 
from  protracted  recumbance  in  a  state  of  health.  Sometimes,  how- 
ever, dysenteric  symptoms  are  present,  especially  if  the  disease  occurs 
during  the  heated  season.  In  one  instance  occurring  in  my  experi- 
ence, an  epidemic  was  characterized  by  the  appearance  of  muco- 
enteritis  among  children,  this  afterward  becoming  complicated  with 
cerebro-spinal  symptoms,  which  soon  became  prominent. 

The  pulse  may  be  only  slightly  accelerated,  or  it  may  be  very 
rapid.  Like  the  temperature,  it  is  liable  to  marked  variation  in  a 
brief  period,  the  pathological  changes  likely  to  occur  in  the  neigh- 
borhood of  the  vaso-motor  and  pneumogastric  centers  suggesting 
the  probability  of  such  a  state  of  affairs.  As  to  quality,  the  pulse 
is  small  and  wiry,  in  the  majority  of  cases,  but  becomes  dicrotio,  late 
in  the  course  of  the  disease. 


CEEEBKO-SPINAL  FEVER.  105 

The  temperature  is  variable,  but  there  is  usually  a  tendency 
toward  a  low  range.  It  is  hardly  ever  above  103°  F.,  and  is  more 
apt  to  range  below  than  above  this  limit.  In  many  casaa,  the  extrem- 
ities are  cool  throughout  the  course  of  the  disease,  and  the  tempera- 
ture of  internal  parts  not  much  above  normal.  However,  in  excep- 
tional cases  a  very  high  temperature  range  may  be  registered  early, 
and  usually,  shortly  prior  to  a  fatal  termination,  there  is  marked  ele- 
vation, even  though  there  has  not  been  much  fever  before.  A  record 
of  the  temperature  in  one  case  is  no  suggestion  as  to  that  of  another; 
the  pathological  changes  occurring  so  near  the  heat  center  seem  to 
disarrange  all  calculations  tallying  with  experience  gained  in  certain 
other  fevers. 

The  eruption  is  usually  limited  to  the  face,  neck,  and  lips,  though 
it  may  appear  on  the  trunk  and  limbs.  Vesicles  resembling  fever- 
blisters  appear  on  the  lips,  and  may  be  limited  to  this  region. 
In  other  cases,  the  eruption  may  resemble  that  of  typhus  fever. 
Ecchymoses  may  appear  on  the  body,  especially  about  the  hips  and 
dorsal  region  where  decubitus  has  caused  pressure,  and  these  are 
particularly  noticeable  after  death.  There  is  no  regular  time  for  the 
eruption  to  appear,  and  no  stated  length  of  time  for  it  to  remain,  it 
being  present  throughout  the  course  of  the  disease  in  some  cases, 
and  only  for  a  single  day  in  others,  while  in  still  others  there  may 
be  all  grades  between  these  limits.  Epidemics  have  occurred  in 
which  the  ecchymoses  were  so  prominent  that  the  disease  was  termed 
"spotted  fever." 

The  senses  are  markedly  affected  in  this  disease.  There  are 
photophobia,  perversion  or  loss  of  taste,  and  deafness.  The  patient 
may  stare  at  one  when  he  is  spoken  to,  or  seem  to,  but  make  no 
reply,  for  the  reason  that  he  does  not  hear  what  is  said;  and 
he  may  not  recognize  the  presence  of  any  one,  when  apparently 
looking  squarely  at  his  interlocutor. 

The  respiratory  tract  is  often  affected,  there  being  sighing  inspira- 
tion, in  some  cases,  and  in  others  irritation,  amounting  to  bronchitis 
or  pneumonia.  Many  other  complications  may  arise. 

Diagnosis. — This  disease  is  readily  diagnosed  from  typhoid 
fever  by  the  irregular  temperature  and  absence  of  abdominal  symp- 
toms. It  resembles  typhus  in  many  of  its  phases — that  is,  many 
cases  do — but  its  non-coutagiousness  and  history  will  prevent  mistake 
in  this  direction.  In  malarious  districts  it  may  at  first  be  mistaken 
for  malarial  fever,  but  its  persistence,  the  early  development  of 
delirium,  opisthotonos,  and  other  nervous  phenomena,  and  refusal  to 
yield  to  anti-malarial  treatment,  will  soon  settle  the  question.  It 
may  be  confounded  with  acute  rheumatism  occasionally,  but  the 


106  SPECIFIC  INFECTIOUS  DISEASES. 

absence  of  acid  sweats,  of  swelling  of  the  joints,  aud  the  presence  of 
rigidity  of  the  muscles,  and  cerebral  symptoms,  will  soon  exclude 
this  disease. 

The  greatest  difficulty  will  be  in  differentiating  between  spo- 
radic cases  of  this  disease  and  tuberculous  meningitis,  where  there 
is  absence  of  tuberculous  material  in  other  situations,  although 
retraction  of  the  muscles  of  the  neck,  and  spasms  of  the  muscles  of 
the  extremities,  are  not  nearly  so  marked  in  the  tuberculous  form. 

Prognosis. — This  is  always  grave,  whether  the  disease  occur 
epidemically  or  sporadically.  It  is  a  disease  subject  to  sudden  and 
repeated  relapses,  and  the  mildest  cases  are  liable  to  finally  termi- 
nate fatally.  Pathological  changes  occur  so  near  the  vital  spot, — 
the  medulla  oblongata, — that  unexpected  extension  of  inflammatory 
action  may  ensue  at  any  time,  and  fatally  involve  vital  function. 
Children  and  elderly  people  are  the  most  unfavorable  subjects. 

The  epidemic  form  usually  lasts  about  fourteen  days,  if  death 
does  not  occur  earlier,  but  an  intermittent  form  may  be  subject  to 
several  apparent  relapses,  and  continue  for  six  or  eight  weeks. 

Serious  sequelae  are  liable  to  follow  recovery,  especially  among 
children,  such  as  deafness,  blindness,  and  impaired  mental  power 
amounting  sometimes  to  idiocy.  Paralysis  of  the  lower  extremities 
may  result,  with  slow  recovery,  several  years  being  consumed. 

Treatment. — The  most  approved  hygienic  treatment  should  be 
adopted  in  the  management  of  epidemics  of  this  disease.  All 
disease-producing  causes  should  be  removed,  such  as  bad  air  and 
improper  food  and  water,  and  the  patient  should  be  placed  in  a 
dark,  cool,  well-ventilated  room,  away  from  all  noise  or  cause  of  dis- 
turbance. The  food  should  be  liquid  in  character,  such  as  milk, 
malted  milk  or  lactated  food,  and  this  should  be  administered  regu- 
larly, and  at  frequent  intervals,  throughout  the  course  of  the  disease. 
To  quench  the  thirst,  cold  water  may  be  given  freely.  Attention 
must  be  paid  to  the  evacuations,  and  catheterizatiou  resorted  to  if 
there  be  retention  of  urine.  Enemata  may  occasionally  be  required 
to  evacuate  the  bowels. 

There  is  little  to  be  expected  from  ordinary  medication  in  the 
treatment  of  this  disease.  Remedies  which  ordinarily  relieve  mus- 
cular paiu  produce  no  alleviation  here,  as  the  pain  is  the  result  of 
pressure  (;n  the  roots  of  the  sensory  nerves,  and  ordinary  anal- 
gesics are  as  good  as  thrown  away  when  administered.  As  much 
may  be  said  of  the  special-sedative  plan  of  treatment.  The  point  of 
irritation  is  so  nea?  the  vaso-motor  center  that  therapeutic  action 
here  is  overpowered  by  the  pathological  condition,  and  aconite, 
veratrum,  gelsemium  and  jaborandi  are  usually  powerless  to  control 


CEREBKO-SPINAL  FEVER.  107 

febrile  action.  Indeed,  there  is  usually  little  call  for  tins  class  of 
agents. 

The  employment  of  cold  baths  and  packs,  ice-bags  to  the  head, 
and  other  depressing  local  agencies,  seems  incompatible  with  good 
judgment,  when  we  stop  to  consider  that  we  are  dealing  with  a  dis- 
ease in  which  there  is  little  reactive  tendency,  and,  almost  invaria- 
bly, a  low  temperature.  The  treatment  ought  to  be  gently  stimu- 
lating, and  supporting  throughout — not  depressing  in  the  least. 

Opiates  should  not  be  administered,  as  they  arrest  secretion, 
debilitate,  and  lessen  chances  of  recovery.  It  is  better  to  restrain 
the  patient  by  force  when  necessary,  using  precaution  not  to  annoy 
or  irritate  him  unreasonably,  until  a  curative  agent  can  have  time 
to  act;  and,  from  the  nature  of  the  case,  this  will  be  but  slowly. 

The  inflammatory  action  in  this  disease  is  not  that  of  simple 
character,  but  is  probably  akin  to  an  erysipelatous  condition,  where 
not  only  sedatives,  but  remedies  which  correct  an  underlying  blood- 
dyscrasia,  are  demanded.  On  this  theory,  I  have  administered  jabo- 
randi  with  some  benefit,  but  have  afterward  found  it  usually  unre- 
liable. Later,  I  began  the  use  of  echinacea,  and  now  believe  that 
I  have  found  the  best  remedy  extant  for  this  disease.  I  cannot 
promise  that  it  will  cure  every  case,  for  I  have  lost  patients  with 
it  who  have  had  the  remedy  from  the  very  beginning,  and  so  have 
some  of  my  professional  friends.  But  it  is,  after  all,  the  only  rem- 
edy I  have  ever  seen  administered  in  this  disease,  with  the  excep- 
tions of  jaborandi  and  rhus  tox.,  which  has  ever  seemed  to  be  of  the 
least  benefit.  Some  cases  will  recover  if  left  to  good  nursing,  and 
under  these  circumstances  claims  may  be  made  in  favor  of  any  plan 
of  treatment;  but  as  some  epidemics  are  light,  a  low  mortality  rate 
would  not  impress  my  mind  favorably  toward  ordinary  methods  of 
medication. 

But  if  echinacea  be  administered  faithfully  throughout  most 
cases,  and  cathartics  and  opiates  be  avoided — as  well  as  sedative 
medication — the  mortality  will  be  found  to  be  very  small,  except  in 
epidemics  of  the  most  violent  character.  Of  course  this  compre- 
hends the  best  nursing  that  can  be  had.  Appropriate  food,  good 
management,  proper  bathing — though  not  too  much  of  this — are 
required ;  and  other  sick-room  needs  must  be  attended  to.  Ten  or 
fifteen  drops  of*  a  good  preparation  should  be  administered  every 
hour  to  an  adult,  the  dose  for  children  being  regulated  to  correspond. 
Let  this  be  continued  throughout  the  disease. 

Bhus  tox.,  in  minute  doses,  may  relieve  the  restlessness,  to  a  lim- 
ited extent,  and  it  also  relieves  thirst  and  controls  nausea.  "Where 
frequent  convulsions  occur  in  infantile  cases,  it  is  the  best  remedy 


108  SPECIFIC  INFECTIOUS  DISEASES. 

we  have  to  combine  with  echinacea,  as  a  cerebral  calmative,  and  anti- 
spasmodic.  Where  there  is  marked  elevation  of  temperature  with 
sthenia,  jaborandi  will  answer  better  in  controlling  the  convulsive 
action  and  restlessness.  The  usual  doses  will  be  proper  here — fif- 
teen or  twenty  drops  of  rhus  to  four  ounces  of  water,  dose  (for  an 
adult),  a  teaspoonful  every  hour.  Two  fluidrachms  of  specific  jab- 
orandi to  four  ounces  of  water,  dose,  a  teaspoonful  every  hour. 

Convalescence  is  usually  slow,  and  care  should  be  observed  during 
this  period  to  prevent  the  patient  from  taking  much  exercise  or 
being  seriously  disturbed  mentally,  for  fear  of  relapse.  One  of  the 
best  safeguards  against  such  an  occurrence  is  the  steady  use  of  ech- 
inacea throughout,  in  the  usual  doses,  repeated  three  or  four  times 
daily. 

V.  SMALL-POX. 

Synonyms. — Variola.     German,  Pocken;  Blatter. 

Definition. — A  contagious,  eruptive  fever,  characterized  by  a 
peculiar  eruption,  which  is  first  papular,  then  vesicular,  and  then 
pustular,  the  disease  being  further  characterized  by  a  secondary 
fever,  which  follows  the  decline  of  the  primary  pyrexia  upon  the 
development  of  the  eruption,  the  remission  continuing  until  the  begin- 
ning of  maturation. 

Etiology. — The  poison  of  small-pox  is  extremely  tenacious,  no 
other  eruptive  fever  being  capable  of  retaining  its  infedling  proper- 
ties in  fomites  so  long.  It  has  made  trips  across  the  Atlantic  from 
Europe,  and  onward  across  the  American  Continent,  in  trunks  of 
clothing,  to  be  afterward  liberated,  to  infect  such  as  were  susceptible, 
who  were  exposed  to  its  influence.  In  such  cases,  the  fomites  will  be 
found  to  contain  particles  of  the  eruption,  in  which  the  virus  exists. 
The  contagiousness  of  such  material  has  been  known  to  remain  for 
years,  Goss,  for  instance,  stating  that  he  knows  of  a  case  where  the 
disease  was  communicated  to  persons  while  cleaning  out  a  cellar 
under  a  house  in  which  patients  had  been  sick  with  small-pox  two 
years  before.  It  can  only  be  produced  by  its  own  contagion,  and  is 
only  communicable  to  persons  who  are  not  protected  from  it,  such 
protection  consisting  in  the  influence  of  a  previous  attack,  and,  to  a 
considerable  extent,  in  vaccination.  A  vigorous  condition  of  the 
system  undoubtedly  fortifies  against  it  to  some  extent,  it  not  being 
so  highly  contagious  as  measles.  The  infectious  principle  exists  in 
the  virus  of  the  pustules,  as  it  may  be  inoculated  from  this  source, 
and  it  may  also  be  conveyed  by  the  breath,  as  well  as  by  exhalations 
from  the  body.  In  this  day,  the  disease  does  not  seem  to  be  as  con- 
tagious as  it  must  have  been  in  olden  time,  as  frequent  exposures 
occur  without  the  communication  of  the  contagion.  As  the  period  of 


SMALL-POX.  109 

maturation  of  the  vesicle  is  asserted  to  be  the  most  infectious  stage, 
the  time  of  exposure  doubtless  explains  why  so  many  are  exposed 
who  escape  the  contagion — i.  e.,  the  disease  does  not  become  highly 
contagious  until  the  vesicle  becomes  maturated.  Yaccination  is 
also  believed  to  have  exerted  a  generally  protective  influence  upon 
the  whole  community,  as  it  was  formerly  a  virulent  and  rapidly  fatal 
disease,  sweeping  pestilence  and  desolation  far  and  wide.  It  is 
asserted  that  during  the  century  preceding  vaccination,  fifty  mil- 
lions of  people  died  of  small-pox  in  Europe.  It  is  also  asserted  that 
the  disease  is  now  dying  out,  and  that  it  only  possesses  historic 
interest,  as  it  hardly  occurs  as  an  epidemic  except  in  uncivilized 
lands  where  the  population  is  unprotected  by  vaccination.  Colored 
races  are  especially  susceptible  to  the  disease,  whether  it  occur  in 
their  native  land  or  where  they  have  been  transported.  In  the  West 
Indies,  where  it  was  conveyed  from  Europe  by  the  Spaniards,  in  1507, 
it  exterminated  whole  races  of  natives ;  and  in  Mexico,  where  it  was 
carried  by  the  Spanish  troops,  three  and  a  half  millions  of  people 
died  from  its  effecta  It  is  asserted  that  wherever  the  whites  and 
Indians  have  lived  in  the  same  neighborhood  since  the  introduction 
of  vaccination,  the  Indians  have  perished  in  large  numbers,  while  the 
whites  have  suffered  comparatively  slight  effects.  One  attack  usu- 
ally confers  immunity,  though  this  is  not  invariable.  The  disease 
occurs  most  frequently  in  cold  seasons,  a  suggestion  that  lack  of 
ventilation  predisposes  to  its  effects.  Nursing  infants  enjoy  some 
immunity,  but  liability  grows  intense  at  the  end  of  the  first  year 
and  continues  up  to  forty,  wfren  it  becomes  less  marked. 

The  specific  cause  is  probably  a  microorganism,  though  this  has 
not  been  identified  as  yet,  after  many  attempts  have  been  made  to 
discover  it.  It  is  believed  that  when  found  it  will  be  discovered  in 
the  pustule.  It  is  probable,  however,  that  the  breath  and  emana- 
tions from  the  body  contain  it  as  well. 

Pathology. — The  most  characteristic  pathological  change  occurs 
in  the  skin,  and  attends  the  development  of  the  eruption.  This 
begins  with  the  formation  of  hardened  nodules  in  the  cutis  vera, 
occasioned  by  swelling  and  proliferation  of  groups  of  cells,  each 
nodule  being  destined  to  become  a  vesicle.  This  cellular  change 
extends  throughout  the  skin  and  involves  the  rete  mucosum,  and  a 
hard,  elevated  nodule  is  soon  developed.  A  process  of  vacuolation, 
occasioned  by  necrobiotic  changes  in  the  interior  cells,  soon  sets  in 
in  this  nodule,  some  deliquescing  to  form  a  set  of  loculated  cavities 
filled  with  fluid  surrounding  a  common  center  of  structure  which 
remains  firm,  holding  the  center  down.  These  cavities  are  filled 
with  a  serous  fluid  containing  red  blooJ-corpuscles  and  leucocytes. 


110 


SPECIFIC  INFECTIOUS  DISEASES. 


As  proliferation  of  cells  and  accumulation  of  fluids  continue,  the 
tense  border  around  rises,  leaving  a  central,  or  umbilicated  depression. 
Some  assert  that  the  center  is  held  down  by  a  sebaceous  gland  or 
hair  follicle,  while  others  aver  that  the  depression  is  occasioned  by 
the  remains  of  undissolved  fibrous  tissue  in  the  nodule.  However 
this  may  be,  the  condition  imparts  a  characteristic  appearance  to 
the  eruption  for  some  time  after  fluid  has  appeared  in  the  vesicle, 
none  other  of  the  exanthematous  fevers  presenting  such  an  appear- 
ance during  eruption.  It  is  seen  that  each  vesicle  is  a  compound 
one,  consisting  of  a  multilocular  aggregation  of  fluid-cavities  around 
a  common  center,  separated  by  delicate  partitions,  and  if  one  of 
these  be  pricked  and  evacuated,  the  others  remain  filled,  unless 
too  much  violence  has  been  employed.  The  fluid  filling  these  vesi- 
TOCK  or  SMALL-POX  cles  is  at  first  clear,  but  it  soon 

becomes  opaque,  and  purulency 
rapidly  ensues,  the  vesicle  being 
converted  into  a  yellow  pustule, 
the  structure  holding  down  the 
center  now  becoming  softened 
and  giving  way,  allowing  the 
umbilicated  depression  to  rise 
and  present,  as  the  apex  of  a 
cone-shaped  eminence.  An  are- 
ola  of  hypersemic  tissue  now 
surrounds  the  base  of  each  pus- 
tule, and  when  they  are  closely 
set,  the  entire  surface  of  the  skin  is  reddened  and  congested.  A 
drying  up  of  the  pustules  is  followed  by  the  formation  of  scales, 
which  dry  most  rapidly  in  the  center,  thus  contracting  and  becom- 
ing depressed,  here  constituting  a  second  umbilicated  stage. 

The  crusts  consist  of  dried  pus-cells  and  epithelial  detritus. 
After  a  time  these  are  thrown  off  by  the  ordinary  exfoliative  process. 
The  suppurative  action  invades  the  true  skin  more  or  less  deeply, 
sometimes  perforating  it,  and  invading  the  subcutaneous  structures. 
Sloughing  of  the  openings  follows,  leaving  cavities  which  heal  by  cic- 
atrization, cup-like  depressions  resulting;  and  a  permanent  pitting 
of  the  skin  is  the  final  effect,  when  the  cutis  vera  is  deeply  involved. 
The  mucous  membrane  of  the  upper  air  passages,  mouth,  fauces,  and 
oesophagus  undergo  modified  changes  of  this  character,  and  the 
organs  involved  are  hyperaemic,  inflamed,  and  more  or  less  ulcerated. 
The  tissue-changes  common  to  protracted  pyrexia  are  more  or 
less  marked  in  nearly  all  the  organs.  In  fatal  cases,  the  blood  is 
dark  and  lacking  in  fibrin ;  there  are  clots  in  the  right  ventricle  of 


SMALL-POX.  Ill 

the  heart;  hemorrhagic  extravasations  are  scattered  about  beneath 
the  mucous  and  serous  membranes;  the  heart,  lungs,  liver,  spleen, 
and  other  internal  organs  are  softened,  and  either  pale,  flabby  and 
swollen,  or  congested.  The  mucous  membranes  are  congested,  sof- 
tened, ulcerated,  their  epithelium  partially  separated  and  covere  1 
with  a  tenacious  mucus,  with  here  and  there  evidences  of  pustula- 
tion,  in  small  round  spots  covered  with  a  false  membrane  or  present- 
ing signs  of  superficial  ulceration.  Peyer's  patches  are  sometimes 
congested,  and  the  pleural  cavity  may  be  filled  with  serous  fluid. 

Symptoms.— The  symptoms  of  this  disease  vary  so  widely  in 
different  cases  that  it  will  be  best  to  give  a  general  outline  first, 
and  particularize  afterward. 

TKe  period  of  incubation  varies  ordinarily  from  seven  to  twelve 
days,  though  in  exceptional  cases  it  may  continue  as  long  as  three 
weeks.  During  this  time  it  is  unusual  for  the  subject  to  complain  of 
unpleasant  symptoms. 

The  onset  of  small-pox,  even  in  mild  cases,  is  usually  abrupt  and 
severe.  There  is  a  marked  chill,  often  nausea  and  vomiting,  fever, 
headache,  and  excruciating  pain  in  the  loins,  this  sometimes  amounting 
to  a  condition  of  temporary  paraplegia.  In  children,  there  may  be 
convulsions  at  the  start,  with  intervening  coma.  The  febrile  action 
is  usually  high,  the  temperature  reaching  103°  or  104°  F.  in  a  few 
hours,  and  ranging  as  high  as  105°  or  106°,  by  the  time  the  eruption 
is  out.  However,  the  temperature  is  often  much  lower,  and  it  may 
not  reach  more  than  102.5°  elevation  during  the  invasion  stage. 
The  tongue  is  usually  coated  with  a  white  covering,  this  often  being 
of  a  dirty,  pasty  character ;  the  pulse  is  accelerated  and  the  skin  is 
moist,  perspiration  usually  being  present  throughout  the  stage  o£ 
invasion.  Soreness  of  the  throat  will  now  be  complained  of,  the 
voice  being  hoarse  and  husky,  and  the  patient  will  complain  of 
pain  in  the  pharynx  and  difficulty  of  swallowing.  The  headache, 
which  is  severe  in  the  beginning,  gradually  increases  until  the  erup- 
tion appears,  when  it  subsides  along  with  the  fever,  backache,  and 
other  unpleasant  features  of  the  invasion  stage.  The  stage  of  inva- 
sion lasts  about  three  days,  and  during  this  time  the  patient  becomes 
considerably  prostrated,  often  being  unable  to  rise  from  bed;  and  he 
may  be  extremely  restless,  and  sometimes  delirious.  During  this 
stage,  the  menses  appear,  in  the  majority  of  women  affected,  whether 
it  be  at  the  proper  time  or  not. 

The  stage  of  eruption  begins  when  minute  red  points  make  their 
appearance  along  the  edge  of  the  hair  on  the  forehead,  on  the  chin, 
and  other  parts  of  the  face.  This  may  be  preceded  by  a  rosolous 
rash,  which  appears  during  the  invasion,  upon  the  inner  aspect  of  the 


112 


SPECIFIC  INFECTIOUS  DISEASES. 


arms  and  thighs.  The  eruption  appears  on  the  scalp  first  and 
spreads  to  the  face,  then  appears  on  the  wrists,  arms,  chest,  neck, 
and  other  parts  of  the  body,  coming  out  lastly  on  the  lower  extremi- 
ties about  twelve  hours  after  its  appearance  on  the  face.  The  pap- 
ules show  a  disposition  to  arrange  themselves  in  groups  of  threes 
and  fives,  scattered  more  or  less  thickly  over  the  surface,  being  most 
abundant  on  the  face.  By  the  second  day,  the  finger  pressed  upon 
them  receives  the  sensation  as  though  a  shot  were  buried  in  the 
skin,  the  nodule  at  first  being  firm  and  resisting.  This  gradually 
rises  on  the  surface.  Soon  the  nodule  is  observed  to  have  become 
umbilicated,  and  to  contain  a  watery  fluid.  The  fever,  headache, 
backache,  and  all  other  unpleasant  symptoms,  except  the  burning 
and  itching  of  the  skin,  now  subside,  and  the  temperature  approaches, 
though  it  does  not  reach  the  normal  standard,  and  it  remains  down 
until  the  stage  of  maturation  has  begun.  Vesicles  may  now  be  seen 
in  the  nares,  mouth,  and  pharynx. 

The  stage  of  suppuration  begins  about  the  eighth  day  of  the  erup- 
tion, or  the  tenth  or  eleventh  day  of  the  disease.  The  fluid  in  the 
vesicles  becomes  turbid  from  the  admixture  of  pus  corpuscles  on  the 
sixth  day,  and  by  the  eighth  the  stage  of  suppuration  is  fully 
established.  A  marked  ring  of  tumefaction  now  surrounds  the  base 


STAGE  OF  SUPPURATION  IN  CONFLUENT  SMALL- POX. 


of  each  pnstule,  the  tissues  being  reddened,  oedematous,  and  swol- 
len; where  the  pustules  are  thickly  set,  the  entire  surface  swells 
remarkably ;  this  is  especially  liable  to  be  the  case  with  the  face 
and  extremities,  where  the  eruption  is  most  apt  to  be  confluent. 
The  eyes  are  obliterated,  to  all  appearance,  the  cheeks  and  nose  are 
frightfully  deformed,  while  the  entire  face  is  covered  by  a  hideous 
mask  of  ripened  pustules,  and  the  hands  and  feet  are  swollen  into 
balls.  A  characteristic  and  sickish  odor  now  emanates  from  the 
patient,  rendering  him  obnoxious  to  the  sense  of  smell,  and  fright- 
ful itching  urges  him  to  tear  and  scratch  the  affected  surface,  which 
oozes  quantities  of  purulent  material.  The  throat  is  swollen  and 


SMALL-POX. 


113 


painful,  and  sometimes  deglutition  is  impossible.  About  the  eighth 
or  ninth  day  of  the  eruption  the  pustule  is  fully  formed,  and  the 
stage  of  suppuration  is  completed.  This  stage  is  usually  ushered  in 
by  a  chill,  and  the  temperature  rises,  sometimes  higher  than  during 
the  stage  of  invasion,  though  manifesting  a  distinctly  remittent  char- 
acter, rising  in  the  evening,  and  declining  in  the  morning.  A  corre- 
sponding increase  in  the  pulse-rate  attends,  high  fever  with  delirium 
frequently  being  present.  Sometimes  there  are  typhoid  symptoms; 
the  tongue  is  heavily  loaded  with  a  pasty,  white  coating,  or  is  brown 
and  dry;  the  patient  is  restless  and  delirious,  lies  in  a  state  of  coma, 
or  mutters  incoherently ;  the  pulse  is  feeble  and  fluttering,  or  quick 
and  tremulous ;  there  is  diarrhoea  with  involuntary  evacuation,  and 
general  prostration  of  all  the  vital  forces.  By  the  eleventh  or  twelfth 
day  of  the  illness,  desiccation  begins,  and  the  fever  and  inflamma- 
tion subside. 

The  stage  of  desiccation  is  occupied  in  the  drying  up  and  casting 
off  of  the  pustules  in  the  form  of  crusts.  This  process  begins  on  the 
scalp  and  face,  where  the  eruption  first  appears,  and  follows  the 
course  of  the  outbreak.  The  redness,  tenderness,  and  oedema  of  the 
skin  now  begin  to  subside,  and  the  purulent  material  becomes  black- 
ened and  hardened  at  the  apices  of  the  pustules,  forming  crusts, 

which  become  puckered,  contracted, 
and  depressed  in  the  center.  Grad- 
ually, the  skin  assumes  its  normal 
color  and  appearance  between  the 
pustules,  and  the  scabs  loosen  and 
separate,  each  leaving  a  reddish- 
brown  stain  with  a  sunken  center, 
which  remains  reddened  for  five  or 
six  weeks  and  then  disappears,  or 
remains  permanent  as  a  whitened 
scar.  With  the  fall  of  the  crusts, 
the  appetite  and  ability  to  sleep 
return,  and  the  patient  begins  to 
regain  health  and  strength. 

Authorities  on  practice  usually 
describe  small-pox  under  three 
forms,  viz.,  (1)  variola  vera,  (2)  vari- 
ola hemorrhagica,  and  (3)  varioloid. 

STAGE  OF  DESICCATION  IN  VABIOLA  CONFLUKNS.  Ya,riolob  VCTd  is  divided    into    two 

divisions,  depending  upon  the  amount  and  extent  of  the  eruption, 
namely,  discrete  and  confluent. 

9 


114 


SPECIFIC  INFECTIOUS  DISEASES. 


The  discrete  variety  is  characterized  by  a  scattered  eruption,  even 
on  the  face  and  hands,  where  it  is  most  marked.  Though  the  symp- 
toms of  the  stage  of  invasion  may  be  severe,  the  eruption  is  not 
attended  by  severe  suffering,  and  the  secondary  fever  is  much  modi- 
tied,  as  compared  with  the  confluent  form,  the  normal  temperature 
being  reached  several  days  earlier,  and  there  being  little  liability  of 
disfigurement  from  pitting. 

„  Confluent  small-pox. — This  is  a  much  more  severe  form  of  the  dis- 
ease than  the  discrete  variety.  The  initiatory  stage  is  shorter  than 
that  of  the  discrete  form,  and  the  symptoms  are  more  violent,  the 
temperature  rising  as  high  as  107°  or  108°  R,  the  pulse  being 


DAY 

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STAGE  OF 
INVASION 

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STAGE  OF 
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-STAGE  OF 
PUSTULES 

STAGE  OF 
CHU3T3 

^TAGE    Or 
DESICCATION 

TEMPERATUBB  IN  A  CASE  OF  SMALL-POX. 


correspondingly  increased  in  frequency.  The  patient  may  be  seized 
with  convulsions,  or  enter  rapidly  into  delirium  or  coma,  from  the 
very  start.  Children,  especially,  are  apt  to  be  seized  with  violent 
and  repeated  convulsions.  The  tongue  is  loaded  with  a  dirty-white 
fur,  or  there  is  obstinate  gastric  irritation  with  persistent  vomiting. 
The  eruption  appears  by  the  second  day,  and  the  red  points  are 
closely  set,  the  entire  surface  being  covered  early  with  a  reddened  tint, 
interspersed  with  numerous  deep-red  points.  The  throat  symptoms 
are  marked  and  distressing,  the  patient  suffering  in  the  early  stage 
with  severe  pain  in  the  pharynx,  and  difficult  deglutition,  as  well  as 
laryngeal  irritation,  attended  by  hoarseness  and  cough.  These 
symptoms  are  much  aggravated  during  succeeding  stages,  oedema  of 
the  glottis,  or  extensive  sloughing  of  the  tissues  of  the  throat,  prob- 
ably succeeding.  The  eruption  forms  large  bullre,  with  flattened  sur- 


•SMALL-POX.  115 

faces  on  the  face,  covering  it  as  a  complete  mask;  and  confluent 
patches  may  appear  on  portions  of  the  body,  though  the  confluent 
eruption  is  chiefly  on  the  face.  The  countenance  is  so  swollen  as  to 
be  unrecognizable,  and  the  suffering  is  intense,  if  the  patient  be  con- 
scious. After  desiccation,  if  the  patient  survive,  large,  contracting 
cicatrices  mark  different  portions  of  the  face,  the  eyes  are  liable  to 
be  destroyed  from  severe  keratitis,  and  other  scarring  results.  Few 
recover  from  malignant  attacks  of  this  form.  Reaction  is  not 
marked  in  the  suppurative  stage  of  this  form,  the  reactive  powers 
being  too  nearly  exhausted;  and  the  temperature  may  even  be  sub- 
normal. The  pustules  may  contain  blood  instead  of  pus,  though 
this  does  not  comprehend  the  hemorrhagic  form  of  the  disease. 

The  hemorrhagic  form  of  small-pox  is  characterized  not  only  by 
the  exudation  of  blood  into  the  pustules,  but  there  are  extravasation 
of  blood  within  the  skin  and  hemorrhages  from  various  mucous  sur- 
faces. H^re  the  symptoms  of  malignancy  manifest  themselves  from 
the  very  start,  and  the  patient  is  liable  to  die  from  exhaustion  or 
septic  poisoning,  before  the  completion  of  the  stage  of  eruption. 

Varioloid  is  an  imperfect  form  of  the  disease,  in  which  the  stages 
are  all  but  faintly  marked,  and  in  which  the  eruption  is  not  fully 
completed.  The  disease  runs  a  mild  course,  and  the  patient  recovers 
without  pitting,  and  without  much  discomfort.  It  occurs  in  persons 
who  are  not  very  susceptible  to  the  disease,  or  who  have  been  pro- 
tected by  vaccination.  That  it  is  genuine  small-pox,  so  far  as  the 
infectious  principle  is  concerned,  however,  is  attested  by  the  facts 
that  an  attack  affords  immunity  from  visitations  of  small-pox,  and 
that  a  susceptibl :  and  unprotected  person  may  contract  variola  in 
severe  form  from  one  affected  with  it  Many  of  the  cases  of  small- 
pox that  are  met  in  modern  time  are  nothing  more  than  varioloid,  the 
almost  universal  resort  to  vaccination  having  partially,  at  least,  pro- 
tected nearly  every  one  from  its  olden-time  ravages. 

Complications. — The  severe  complications  which  formerly  attended 
this  disease  are  not  so  common  in  these  days,  probably  because  the 
treatment  has  become  more  rational,  as  well  as  the  affection  less 
severe.  Probably  the  most  numerous  of  these  occur  in  hospitals, 
where  many  patients  are  congregated.  Severe  cases,  however,  are 
liable  to  be  complicated  with  destructive  inflammation  of  many  dif- 
ferent parts  and  organs. 

Pulmonary  complications  are  probably  the  most  serious  and  fre- 
quent. (Edema  of  the  glottis  and  asphyxia,  unless  tracheotomy  be 
performed,  frequently  occurs  in  severe  cases.  Severe  bronchitis, 
with  extension  of  the  inflammation  to  the  small  tubes,  is  likely  to 
occur  in  children.  Pneumonia  not  unfrequently  occurs,  and  effusion 


116  SPECIFIC  INFECTIOUS  DISEASES. 

into  the  pleura!  sac  from  involvement  of  the  pleura,  is  then  apt  to 
follow.  A  sequel  to  severe  pulmonary  inflammation  may  be  peri- 
cardial  inflammation,  resulting  in  hydrops  pericardii  or  fatty  degen- 
eration of  the  walls  of  the  heart 

Cellular  abscess  involving  the  cutaneous  tissues  may  result  from 
the  extension  of  boils  through  the  skin,  in  scrofulous  children.  lu 
such  cases  extensive  gangrene  may  attend  the  suppurative  action. 

Sloughing  of  delicate  parts,  such  as  the  scrotum  and  labia,  may 
occur  in  children,  especially  those  of  scrofulous  tendency,  and  deep- 
seated  abscesses  may  be  attended  by  phagedenic  ulceration,  upon 
their  discharge. 

Inflammation  of  the  conjunctiva,  with  severe  ulceration  of  the 
cornea,  often  with  destruction  and  evacuation  of  the  humors,  was 
once  quite  a  common  complication. 

Otitis,  with  destruction  of  the  structures  of  the  internal  ear  and 
extensive  ulceration  of  the  osseous  portion,  is  among  the  possibil- 
ities of  severe  cases  of  this  disease. 

Suppuration  of  the  joints;  destruction  of  the  hair  follicles,  rendering 
the  patient  permanently  bald;  bed-sores;  meningitis;  and  paralysis, 
may  be  looked  for  in  very  bad  cases. 

Diagnosis. — The  history  of  the  case  may  throw  some  light 
upon  it,  where  a  diagnosis  is  called  for  early  in  the  disease.  Is  the 
patient  an  immigrant,  recently  from  some  public  route  of  travel,  or 
has  he  been  exposed  to  the  influence  of  fomites  of  such  character? 
Or,  is  there  any  account  of  suspicious  eruptive  fever  in  the  neighbor- 
hood? The  fact  that  the  patient  has  been  vaccinated  does  not  mili- 
tate very  much,  as  its  protection  may  have  passed  away.  The  onset 
of  variola  is  sudden,  abrupt.  The  temperature  rises  rapidly,  the 
pain  in  the  loins  is  excruciating,  and  the  tongue  is  coated  white,  and 
not  of  the  strawberry  character  of  the  scarlatina  tongue.  The  erup- 
tion is  also  much  more  "shotty"  in  feel  than  measles,  and  it  is  more 
macularin  appearance  than  scarlatina;  not  so  punctate.  The  catar- 
rhal  symptoms  are  not  so  marked  early  in  measles,  and  the  erup- 
tion does  not  spare  the  nose  or  region  of  the  mouth,  as  does  scarla- 
tina. When  the  vesicles  are  developed,  there  can  be  no  mistake. 

Prognosis. — In  these  times,  the  prognosis  of  small-pox  is  much 
more  favorable  than  formerly.  If  treatment  be  at  all  modern,  few 
cases  take  on  the  severer  form,  and  the  pitting  and  other  sequelae 
are  slight  Unfortunately,  most  cases  are  left  to  the  care  of  the 
health  officer,  who  is  usually  of  the  kind  which  employs  the  most 
unsuccessful  therapeutic  measures;  but  still  the  mortality  is  usually 
low  after  all,  owing  to  the  modified  form  in  which  the  disease 
generally  appears. 


SMALL-POX.  117 

When  the  confluent  form  is  present,  the  prognosis  is  much  more 
grave;  and  hemorrhagic  variola  is  exceedingly  fatal,  very  few  recov- 
ering. There  are  so  many  complications  of  serious  nature  attending 
coufluent  small-pox,  that  death  from  exhaustion  is  liable  to  occur 
during  the  third  week,  after  the  infectious  disease  has  run  its 
course. 

Age  and  sex  determine  something  in  regard  to  mortality;  infants 
and  old  persons  are  bad  subjects,  and  likely  to  die  if  the  disease  is 
severe.  Women  do  not  endure  the  disease  as  well  as  men,  probably 
owing  to  the  almost  inevitable  menstrual  disturbance.  A  severe 
invasion  is  not  always  indicative  of  a  confluent  eruption  and  serious 
after-effects,  as  the  eruption  may  be  slight,  and  the  remaining  por- 
tion of  the  case  mild. 

Hemorrhages  occurring  from  several  of  the  mucous  surfaces — 
different  organs — may  be  considered  indicative  of  serious  results; 
or  early  extravasation  of  blood  into  the  vesicles,  or  into  the  skin. 

Pregnancy  is  an  unfavorable  condition  for  a  patient  with  small- 
pox. (Edema  of  the  glottis  is  a  complication  that  offers  poor  hopes 
of  recovery,  as  tracheotomy  is  imperatively  demanded,  and  this 
becomes  a  serious  operation  under  such  circumstances. 

Treatment. — The  prophylactic  treatment  will  consist  of  vac- 
cination, immediately  after  exposure,  or  as  soon  as  possible.  If 
this  should  fail  to  arrest  the  disease,  it  promises  to  at  least  lessen 
its  severity.  The  diet  should  be  regulated  during  the  stage  of  incu- 
bation, so  that  all  greasy  and  stimulating  food  may  be  avoided,  light, 
farinaceous  foods  and  fruit  only,  being  allowed.  Plenty  of  pure  air 
is  important  in  this  disease,  and  it  should  be  seen  that  rooms  occu- 
pied by  small-pox  patients  are  well  supplied  with  this  essential  to 
successful  treatment.  Loomis  asserts  that  the  most  satisfactory 
treatment  employed  in  small-pox  epidemics  with  which  he  was  con- 
nected, was  administered  in  barracks,  where  there  were  snow-drifts 
on  the  floor  of  the  wards  occupied  by  the  patients.  Pent-up  air  is 
quite  likely  to  develop  bad  cases  out  of  those  which  might  otherwise 
be  light,  and  must  be  avoided. 

The  medicinal  treatment  will  consist  in  following  out  the  simplest 
indications.  The  morbid  changes  which  occur  in  the  skin,  develop 
the  serious  aspects  of  all  bad  cases,  and  if  these  can  be  modified  or 
controlled,  a  mild  course  is  assured.  Remedies  which  lessen  the 
initial  hypersemia  will  modify  the  later  action  and  ameliorate  symp- 
toms, if  they  do  not  shorten  the  disease. 

Eclectics  will  resort  to  the  special  sedatives  early,  even  before 
the  true  character  of  the  disease  is  fully  developed ;  and  this  method 
is  the  philosophical  plan,  as  it  will  control,  to  a  certain  extent,  the 


118  SPECIFIC  INFECTIOUS  DISEASES. 

cutaneous  hyperaBmia.  The  whole  class  of  remedies  of  this  group- 
aconite,  veratrum,  gelsemium,  jaborandi — may  be  applicable,  in 
treating  several  cases.  But  wherever  there  is  not  gastric  irrita- 
tion to  contraindicate  it,  jaborandi  will  be  the  preferable  one,  on 
account  of  the  directly  sedative  influence  it  possesses  on  the  skin. 
Two  or  three  drachms  of  the  specific  medicine,  or  some  other  relia- 
ble preparation,  should  be  added  to  half  a  glass  of  water,  and  a  t'-.-i- 
spoonful  should  be  administered  every  hour,  as  soon  as  the  initial 
fever  begins.  This  will  be  an  excellent  prescription  to  follow  until 
the  fever  subsides,  as  its  cooling,  soothing  influence  upon  the  skin, 
through  the  systemic  circulation,  will  be  highly  appreciated  by 
the  patient. 

But  the  frequent  occurrence  of  nausea  and  vomiting  will  pre- 
clude such  treatment  in  many  cases,  and  something  more  adapted 
to  gastric  irritability  will  be  demanded.  Here  we  may  expect  tie 
best  results  from  rhus  tox.  and  aconite,  in  the  usual  proportions, 
five  or  six  drops  of  aconite  and  fifteen  or  twenty  of  rhus  to  four 
ounces  of  water,  dose,  a  teaspoonful,  for  an  adult,  every  hour. 

The  sodium  sulphite  tongue — excessive  acidity  with  sepsis,  as 
indicated  by  the  dirty  pasty  coating — should  not  be  disregarded 
in  the  treatment.  The  nearer  we  can  bring  the  condition  of  the 
patient  to  a  standard  of  health  in  a  general  way,  the  less  severe  will 
be  the  later  stages  of  the  disease.  The  brown  coating  on  the  tongue 
suggesting  sulphurous  acid  may  occasionally  be  present,  and  the 
suggestion  should  be  heedei.  As  an  intercurrent  remedy,  to  fortify 
the  blood  against  septic  changes,  and  also  fortify  the  tissues  against 
suppuration  and  sloughing,  we  certainly  cannot  do  better  than 
administer  echinacea.  Ten  drops  of  echinacea  should  be  given 
every  second  hour  throughout  the  course  of  the  disease,  as  it  will 
be  almost  certain  to  modify  the  tendency  to  pitting,  as  well  as  pro- 
vide against  septic  changes  liable  to  attend  the  extensive  accumula- 
tion of  purulent  material  upon  the  cutaneous  surface. 

In  no  other  form  of  eruptive  fever  is  the  use  of  baths,  to  cleanse 
and  soften  the  skin,  so  important  as  here.  From  the  very  beginning, 
the  surface  should  be  sponged  frequently,  with  warm  water  and  unir- 
ritating  soap,  such,  for  instance,  as  Loyd's  Asepsin  Soap,  or  some 
mild  and  cleansing  preparation  of  the  kind.  A  bath  of  this  charac- 
ter should  be  administered  several  times  a  day  by  sponging  the  sur- 
face, and  after  the  eruption  it  should  be  continued,  with  the  free 
use  of  some  emollient  application,  to  prevent  the  skin  from  harden- 
ing and  imprisoning  the  pus,  during  the  stage  of  suppuration. 

Pitting  of  the  face  is  to  be  avoided,  if  possible,  and  to  provide 
against  this  the  skin  over  the  part  should  be  kept  especially  moist, 


SMALL-POX.  119 

and  the  air  and  light  should  be  excluded.  For  this  purpose  a  mask 
should  be  worn,  this  being  fashioned  from  a  piece  of  muslin,  of 
appropriate  shape,  with  openings  for  the  mouth,  nose,  and  eyes. 
This  should  be  wetted  every  hour,  in  a  dilution  of  an  ounce  each  of 
specific  echinacea  and  glycerine,  in  six  ounces  of  water.  Each  time 
the  mask  is  removed  for  saturation,  the  face  should  be  well  sponged 
with  tepid  water  rendered  slightly  alkaline  with  mild  soap.  Or, 
the  following  solution  may  serve  better  to  control  the  itching: 
#  Resorcin  ji,  glycerine  fss,  water  f vi,  M.  Apply  with  soft  sponge, 
every  hour. 

Muscular  pain,  during  the  initiatory  and  eruptive  stages,  may 
demand  special  attention.  Jaborandi  is  a  verv  applicable  remedy, 
and,  as  it  has  been  recommended  for  the  initial  fever,  it  will  meet 
this  indication  as  well.  However,  sometimes  we  may  find  it  an 
assistance  to  resort  to  cimicifuga  or  phenacetin.  Rhamnus  cah 
may  be  found  to  answer  well  here,  though  where  there  is  any  ten- 
dency to  diarrhoea  it  would  be  better  to  depend  upon  some  other 
remedy.  The  backache  may  also  be  much  relieved  by  the  'applica- 
tion of  hot  cloths  to  the  part,  though  the  treatment  for  muscular 
pain  will  probably  prove  sufficient. 

Complications  must  be  met  with  appropriate  treatment.  (Edema 
of  the  glottis  will  demand  prompt  tracheotomy.  Pneumonia  should 
be  treated  by  packing  the  chest  with  cloths  wrung  out  of  tepid  water, 
in  addition  to  proper  internal  agents,  though  echinacea  will  be  as 
appropriate  as  any  remedy  iu  fiis  case.  Boils  and  abscesses  should 
be  opened  early,  and  well  cleansed  with  diluted  tincture,  or  specifics 
echinacea.  Mouth  and  throat  complications  will  be  pretty  well 
provided  for  by  the  general  treatment. 

There  may  be  times  when  a  stimulant  may  be  demanded  to  pre- 
vent fatal  collapse,  though  where  echinacea  is  used  properly  through- 
out the  course  of  the  disease  alcoholic  stimulants  will  be  rather 
inefficient,  provided  it  should  fail  to  sustain  the  vitality.  However, 
should  signs  of  sinking  occur,  the  judicious  exhibition  of  brandy  or 
whisky  is  regarded  as  good  treatment  in  some  quarters,  and  cer- 
tainly cannot  be  objected  to  in  desperate  cases.  However,  alcoholic 
stimulants,  usually,  should  be  tabooed,  as  their  stimulating  effects  are 
calculated  to  aggravate  inflammatory  action  and  its  later  result, 
suppuration. 

During  the  stage  of  desiccation,  daily  baths  of  warm  water  will 
assist  in  softening  the  crusts  and  render  the  skin  more  soft  and  pli- 
able. After  each  bath  the  skin  should  be  well  oiled,  the  inunction 
assisting  in  the  process  of  desiccation,  and  also  acting  as  a  protection 
to  the  weakened  cutaneous  surface,  guarding  against  chilling  of  the 


120  SPECIFIC  INFECTIOUS  DISEASES. 

cutaneous  capillaries.     The  diet  should  be  mild  and  unstimulating, 
but  nourishing  and  assimilable. 

SUPPLEMENTAL  THERAPEUTCIS. — Some  think  highly  of  inaugurating 
the  treatment  with  a  thorough  alcoholic  vapor  bath.  This  is  doubt- 
less excellent  to  relieve  the  lumbar  pain,  while  it  may  assist  internal 
agents  in  modifying  the  entire  course  of  the  disease.  A  thorough 
emetic  may  be  employed  with  good  results  in  malignant  cases  marked 
by  drowsiness  with  tendency  to  coma,  and  cold  extremities  with  fee- 
ble pulse.  Some  practitioners  believe  in  small-pox  specifics.  Two 
%gents  prominently  recommended  by  their  respective  admirers  are 
timicifuga  and  sarracenia  purpurea — pitcher  plant.  In  the  use  of 
either  of  these  a  decoction  is  preferred,  the  dose  being  a  tablespoon- 
ful,  repeated  every  three  or  four  hours. 

VI.  VACCINATION. 

Definition. — The  introduction  of  cow-pox  into  the  human  sys- 
tem, as  a  protection  against  small-pox. 

History. — In  1776,  Dr.  Edward  Jenner  observed  that  in  some 
of  the  northern  counties  of  England,  employe's  of  the  dairies  there 
who  suffered  from  a  certain  form  of  ulcer  upon  their  hands  appar- 
ently contracted  from  cows  while  milking,  possessed  immunity  from 
small-pox.  Like  many  other  medical  discoveries,  however,  this  fact 
was  known  to  the  people  a  long  time  before  Jenner  noticed  it,  and 
his  attention  was  probably  first  called  to  it  through  this  medium. 
History  has  it  that  a  Holsteiu  schoolmaster  vaccinated  three  pupils 
in  1771,  and  in  1774  an  English  farmer  vaccinated  his  wife,  because 
of  his  belief  in  the  power  of  bovine  virus  to  prevent  small-pox,  as 
seen  in  his  dairy-maids. 

Jenner  maile  his  first  vaccination  on  a  man  in  1796,  and  published 
his  belief  in  the  doctrine  first  in  1798.  Waterhouse,  of  Boston, 
introduced  the  practice  into  this  country  in  the  following  year,  and 
in  1800,  it  was  introduced  into  France.  For  the  first  six  years  after 
the  announcement  of  his  discovery,  Jenner  was  subjected  to  the  most 
outrageous  villification  and  abuse  imaginable  by  his  countrymen,  all 
over  Great  Britain.  He  was  attacked  by  the  leading  physicians  and 
sujgeons,  reviled  and  denounced  from  the  pulpit  by  the  clergy, 
and  scoffed  at,  as  the  "crack-brained  doctor,"  by  the  common  people. 
Placards,  containing  caricatures  of  Jenner,  were  posted  throughout 
the  principal  streets  of  London  and  other  large  cities  and  towns  of 
Great  Britain,  and  he  was  treated  to  many  other  indignities.  Within 
six  years,  however,  there  was  a  revolution  of  sentiment,  Jenuer,  by 
this  time,  having  compelled  the  profession,  by  his  success,  to  aJopt 


VACCINATION.  121 

his  views;  and  soon  afterward,  vaccination  became  generally  prac- 
ticed for  the  prevention  of  small-pox. 

But  the  opposition  did  not  altogether  cease  here.  In  spite  of 
the  fact  that  almost  the  whole  world  was  convinced,  when  small-pox 
was  ravaging  Europe  and  there  was  so  favorable  au  opportunity  to 
observe  the  contrast  between  those  protected  and  those  unprotected, 
a  small  minority  maintained  their  opposition;  and  there  exists  to-day, 
in  England,  and  to  a  limited  extent  in  America,  a  class  of  people 
calling  themselves  anti-vaccinationists.  They  assert  that  they  do 
not  object  to  the  vaccination  of  others,  but  they  cry  oat  against  com- 
pulsory laws  demanding  it  upon  themselves.  They  claim  the  privi- 
lege of  being  let  alone,  and  being  allowed  to  face  small-pox  without 
the  protection  of  kme-pox.  They  dwell  upon  tales  of  horrible 
diseases  transmitted  by  vaccination,  such  as  syphilis,  scrofula,  skin 
diseases,  etc.,  and  of  erysipelas  and  other  serious  conditions  being 
transmitted  or  developed,  through  the  operation.  In  twenty-six 
years,  I  have  never  seen  anything  worse  than  a  few  mild  cases  of 
erysipelas,  though  there  doubtless  are  exceptional  instances  where 
vaccination  may  result  very  injuriously.  Accidents  may  sometimes 
occur  in  the  simplest  affairs  of  life.  I  once  knew  a  man  to  die 
through  having  a  corn  cauterized  with  sulphuric  acid ;  but  this  need 
not  forever  taboo  the  practice  of  attempting  to  destroy  corns.  The 
kind  of  freedom  desired  by  the  anti-vaccinatonists  would  be  like 
that  which  permitted  a  man  to  burn  down  his  own  house  whether  it 
joined  that  of  a  neighbor  or  not;  welfare  of  the  neighbor's  house,  in 
his  opinion,  seemingly,  ought  to  hold  no  comparison  to  his  own 
personal  freedom.  The  proper  kind  of  liberty  is  that  which  confers 
the  greatest  good  upon  the  greatest  number.  However,  no  doubt 
the  anti-vaccinationists  have  been  beneficial  to  mankind.  Their 
outcry  has  been  conducive  to  greater  caution  in  the  preparation  and 
introduction  of  material  for  use  in  vaccination,  in  order  that  bad 
results  may  be  avoided.  Non-humanized  virus  is  now  largely  used, 
it  being  obtained  by  inoculating  healthy  calves,  the  management 
of  vaccine  farms  being  followed  as  a  special  business.  The  material 
is  usually  furnished  to  physicians  through  the  drug  trade. 

However,  non-humanized  virus  soon  loses  its  specific  contagium, 
and,  if  the  material  is  not  of  recent  origin,  it  is  very  liable  to  fail  to 
produce  the  desired  effect.  Even  when  fresh,  it  is  estimated  that  it 
will  prove  successful  in  only  about  70  per  cent  of  the  cases  treated. 
According  to  my  own  observation,  50  per  cent  would  be  a  better  esti- 
mate. Where  several  children  are  vaccinated  at  the  same  time  in  a 
certain  family,  and  the  operation  proves  successful  in  ono,  it  cannot 
be  improper  to  vaccinate  the  others  of  the  same  family  from  this 


122 


SPECIFIC  INFECTIOUS  DISEASES. 


vesicle,  provided  it  has  developed  a  normal  course;  for  humanized 
virus  is  much  more  reliable  than  auimal.  If  symptoms  of  ery- 
sipelas or  severe  inflammation  should  develop  daring  its  course, 
there  would  be  good  reason  for  avoiding  this  virus,  and  it  would 
not  be  likely  to  contain  the  element  of  cow-pox  infection.  It  would 
be  a  better  plan,  however,  not  to  vacciuatu  those  of  another  family, 
as,  if  there  should  be  any  objectionable  taint  in  the  first,  it  might  be 
conveyed  to  others,  in  this  manner. 

Vaccine  virus  is  now  usually  supplied  to  the  market  in  the  shape 
of  "points,"  these  being  thin  slips  of  pointed  bone,  the  tips  of  which 
have  been  dipped  into  the  contents  of  a  Lovine  cow-pox  vesicle,  and 
dried,  for  the  market. 

Vaccination  consists  in  moistening  the  tip  or  point  of  one  of  these 
in  pure  water,  ana  with  it,  scratching  the  cuticle  away  from  over  an 
area  of  about  a  fourth  of  an  inch  in  diameter  on  the  arm,  above  the 
insertion  of  the  deltoid  muscle.  The  scratching  should  be  done  so 


that  one  series  of  scratches  will  cross  that  of  another,  and  it  should 
be  continued  until  slight  capillary  hemorrhage  appears  upon  the 
abraded  surface.  When  this  occurs,  the  point  should  be  again 
moistened,  and  both  sides  of  the  portion  covered  with  virus  should  be 
carefully  and  sedulously  rubbed  upon  the  abraded  surface,  until  the 
material  has  been  thoroughly  incorporated  with  the  oozing  fluid,  and 
forced  into  the  ruptured  capillaries.  The  operation  of  vaccination' 
from  the  arm  of  one  subject  to  that  of  another,  is  very  simple.  A 
needle  may  be  thrust  inlo  the  ripened  vesicle,  and  afterward  pushed 
into  the  skin  of  the  one  to  be  vaccinated.  To  render  the  infection 
more  certain,  the  operation  may  be  repeated,  the  point  being  intro- 
duced a  second  time  into  the  first  puncture  made  in  the  arm  of  the 
person  to  receive  vaccination. 

If  the  vaccination  passes  through  the  following  stages,  it  may  be 
considered  as  having'  exerted  a  protective  influence  upon  the  subject: 
Upon  the  third  day  after  the  vaccination,  there  will  be  developed 
upon  the  site  of  the  operation  a  small  red  point  or  papular  elevation, 
which  becomes  a  bluish-white  vesicle,  and  upon  the  fifth  day  there 
will  be  developed  around  this  a  yellow  margin.  This  vesicle  increases 
slowly  in  size  up  to  the  eighth  day,  when  it  is  seen  to  be  umbili- 
cated.  A  reddish  areola  now  appears,  developing  around  it,  this 


CHICKEN-POX.  123 

showing  faintly  on  the  seventh  day,  and  being  very  distinct  by  the 
ninth.  This  areola  continues  to  increase  in  size,  spreading  around 
the  vesicle  for  three  or  four  days  more,  until,  by  the  eleventh  or 
twelfth  day  it  may  be  one  or  two  inches  in  width  from  the  vesicle,  in 
all  directions,  and  the  redness  be  marked.  The  arm  will  now  be 
swollen  and  elevated  about  the  vesicle,  the  neighboring  axillary 
glands  will  be  hardened  and  enlarged,  and  the  arm  and  axillary 
region  somewhat  tender  and  painful  The  pustule  ruptures  on  the 
twelfth  or  thirteenth  day,  and  by  the  fifteenth  the  crust  is  found  to 
have  assumed  a  brown  color,  which  deepens  until  the  seventeenth  or 
eighteenth.  This  falls  off  spontaneously  on  the  twentieth  or  twenty- 
fifth  day,  leaving  a  purplish-red  scar,  which  gradually  turns  white. 
Meantime,  after  the  rupture  of  the  vesicle,  the  reddened  areola  grad- 
ually fades  away,  and  the  swelling  and  tenderness  subside,  until  "by 
the  time  of  the  fall  of  the  crust  the  soreness  and  inflammation 
have  completely  disappeared. 

If,  instead  of  the  vesicle  on  the  eighth  day  a  pustule  be  formed, 
a  disturbance  of  the  regular  development  of  a  vaccine  vesicle  is 
announced,  and  the  vaccination  cannot  be  considered  as  protective. 
The  intervention  of  erysipelas  is  very  liable  to  destroy  the  specific 
character  of  the  vesicle,  and  interfere  with  the  protective  effect  of 
the  operation. 

Yaccination  should  be  resorted  to  during  the  first  year  of  life, 
and  again  every  seventh  year  until  puberty;  it  should  then  be 
repeated  again,  as  the  protection  gradually  dies  out.  After  this,  and 
before  as  well,  vaccination  should  be  repaated  upon  the  advent  of 
every  case  of  small-pox  into  the  neighborhood. 

VH.  CHICKEN-POX. 

Synonym. — Varicella. 

Definition. — A  mild,  acute,  infectious,  eruptive  disease,  chiefly 
affecting  children,  characterized  by  a  vesicular  rash  involving  the 
superficial  layers  of  the  epidermis,  attended  by  slight  febrile  dis- 
turbance, no  important  sequelae,  and  favorable  prognosis. 

Etiology. — This  is  a  disease  of  infancy  and  childhood,  in  a 
large  majority  of  cases,  though  it  may  occur  during  adolescence,  and 
even  in  adult  life,  in  rare  cases.  However,  such  a  large  majority  of 
cases  occur  during  and  before  the  first  two  or  three  years  of  age, 
that  the  physician  seldom  sees  it  in  later  life,  especially  after  the 
sixth  year.  It  is  said  that  infants  under  six  months  of  age  enjoy  a 
certain  amount  of  immunity.  It  does  not  occur  in  marked  epidemics, 
as  some  of  the  other  eruptive  fevers,  but  is  liable  to  appear  in  large 
cities  at  all  seasons  of  the  year  and  at  all  times,  its  appearance  seem- 


124  SPECIFIC  INFECTIOUS  DISEASES. 

ing  to  be  sporadic  in  character,  in  some  cases.  The  disease  is  con- 
tagious, the  respired  air  being  the  medium  of  contagion,  probably, 
though  it  is  asserted  that  it  may  be  conveyed  by  a  third  person. 
Though  efforts  have  been  made  to  isolate  the  microorganism  of  this 
contagion,  they  have  so  far  been  f  utile.  For  a  long  time  there  was 
much  confusion  as  to  the  identity  of  this  disease,  many  believing  it 
to  be  a  modified  form  of  small-pox,  identical  with  the  irregular  cases 
of  varioloid  which  occur  after  partial  protection  by  vaccination. 
But  the  fact  that  such  cases  may  originate  small-pox  in  the  unpro- 
tected, while  varicella  never  produces  such  a  result,  establishes  the 
identity  of  this  disease  as  a  distinct  affection. 

Pathology. — The  only  distinguishable  morbid  condition  aris- 
ing from  this  disease  is  that  occasioned  by  the  cutaneous  eruption. 
This  consists  of  numerous  minute  red  spots,  varying  from  twenty- 
five  to  two  hundred,  which  soon  become  small  vesicles  containing  a 
clear,  watery,  alkaline  fluid.  These  rest  on  a  hypersemic  base,  though 
in  many  cases  the  areola  is  absent.  There  seems  to  be  a  division  of 
opinion,  as  to  the  internal  structure  of  these  vesicles,  some  main- 
taining that  they  consist  of  a  single  cavity,  while  others  assert  that 
they  are  divided  into  compartments  by  delicate  partitions.  From 
other  testimony,  it  seems  that  some  consist  of  single  compartments, 
and  others  may  be  divided.  As  the  superficial  layers  of  the  skin 
only  are  involved,  the  structure  is  so  delicate  that  the  vesicles  do  not 
bear  much  investigation  without  rupturing.  They  arise  from  an 
exudation  underneath  the  superficial  layers  of  the  epidermis,  lift- 
ing them  from  the  rete  malpighii,  this  layer  not  being  involved. 
The  eruption  may,  and  often  does,  involve  the  mucous  membrane  of 
the  mouth  and  throat;  and  even  the  alimentary  canal  may  suffer. 
Sometimes,  however,  the  deeper  layers  are  involved,  and  even  the 
true  skin  may  become  ulcerated,  and  pitting  result.  However,  this 
is  more  likely  to  be  the  effect  of  scratching. 

Symptoms. — The  period  of  incubation  usually  occupies  from 
ten  to  fifteen  days.  The  invasion  stage  of  varicella  is  more  generally 
absent  than  observable.  Generally  the  first  symptom  noticeable 
will  be  the  rash,  and  this  will  appear  while  the  child  is  playing 
about,  and  making  no  complaint.  The  physician  is  then  summoned, 
because  the  mother  becomes  alarmed,  and  desires  a  diagnosis  made 
of  the  condition.  Again,  the  rash  may  be  attended  by  a  slight  fever- 
ishness,  which  occasions  peevishness  and  irritability.  The  temper- 
ature may  be  found  at  101°  or  102 "  F.,  though  rarely  higher,  and 
not  often  as  high  as  102°.  Still,  there  may  be  some  complication  in 
other  cases,  which  will  occasion  considerably  more  elevation  of  tem- 
perature, such,  for  instance,  as  malarial  fever.  I  have  seen  this 


CHICKEN-POX.  125 

disease  complicated  in  this  way  and  attended  by  a  regular  remittent 
fever,  with  morning  remissions  and  afternoon  exacerbations,  the 
temperature  reaching  103°  and  more.  In  such  cases  the  eruption 
may  be  the  source  of  considerable  discomfort  from  the  itching 
occasioned,  when  the  fever  is  at  its  height.  Sometimes  the  eruption 
in  the  mouth  becomes  a  marked  source  of  irritation,  much  smarting 
and  burning  being  occasioned  when  the  patient  partakes  of  food. 

The  eruption  appears  at  first  as  small,  red,  slightly-elevated  spots, 
resembling  the  rose-rash  of  typhoid  fever  in  appearance,  which  come 
out  first  on  the  upper  part  of  the  back  and  chest,  and  spread  rapidly 
over  the  body,  face,  scalp,  and  extremities.  The  face,  especially  the 
forehead  and  temples,  furnishes  the  most  characteristic  and  abun- 
dant eruption.  There  is  great  variability  as  to  the  abundance  of  the 
eruption,  some  cases  furnishing  only  a  few  scattered  vesicles,  while 
others  cover  the  entire  cutaneous  surface  thickly.  A  few  hours  after 
the  maculae  or  hypersemic  spots  appear,  a  small  vesicle  can  be 
observed  in  the  center  of  each  macula,  and  this  quickly  enlarges  to 
its  full  size.  When  developed  fully,  the  vesicles  are  ovoid  or  round 
in  form,  and  vary  in  size  from  that  of  a  pin-head  to  that  of  a  small 
pea.  They  are  thinly  covered,  being  quite  superficial,  incased  only 
by  the  outer  layers  of  the  epidermis,  and  the  covering  is  on 
the  stretch,  while  there  may  be  a  slight  zone  of  redness  about 
the  base.  These  are  so  shiny  and  glistening  in  many  cases  as  to 
resemble  drops  of  water  on  the  skin.  They  are  sometimes  congre- 
gated into  small  groups,  resembling  zoster.  The  fluid  in  these 
vesicles  is  clear  as  water  at  first,  and  invariably  of  an  alkaline  reac- 
tion. As  the  vesicles  mature,  they  may  become  cloudy  and  yellowish 
from  the  presence  of  a  few  pus-cells,  but  they  never  become  purulent. 
Fresh  crops  of  maculae  succeed  each  other  by  a  few  hours  two  or 
three  times,  so  that  the  vesicles  may  be  observed  in  all  stages  of 
progress  over  a  limited  area,  though  those  which  appear  first  are 
the  most  perfectly  formed,  many  of  the  later  masculse  never  pass- 
ing beyond  the  vesicular  stage,  but  fading  away  soon  after  their 
appearance.  Others  form  small  and  imperfect  vesicles,  but  these  do 
not  arrive  at  maturity.  By  the  second  or  third  day  the  eruption 
begins  to  decline,  the  vesicles  becoming  wrinkled  and  flaccid,  from 
partial  absorption  of  their  contents.  Others  grow  tense  and  burst, 
and  still  others  are  ruptured  by  the  patient,  while  scratching.  As 
they  dry  up,  they  form  thin,  brownish  crus.ts.  In  a  few  days,  the 
crusts  fall  off  or  are  scratched  off,  leaving  reddish  patches  of  skin  at 
their  sites,  which  gradually  assume  the  normal  tint.  In  some  cases 
ulceration  of  the  skin  occurs,  and  permanent,  pitted  scars  remain. 

If  the  mouth  and  throat  are  examined  during  the  stage  of  erup- 


126  SPECIFIC  INFECTIOUS  DISEASES. 

tion  vesicles  may  be  found  here,  they  being  most  numerous  on  the 
palate,  hard  and  soft.  Thesa  soon  rupture,  leaving  small  ulcers, 
which  sometimes  become  quite  irritable.  Sometimes  the  cervical 
glands  are  slightly  enlarged  and  tender.  The  prepuce  and  vagina 
may  become  the  seat  of  vesicles,  and  when  this  is  the  case,  painful 
urination,  and  smarting  following  the  act,  are  complained  of.  A 
severe  diarrhoea  occurring  during  this  stage  would  suggest  the  pres- 
ence of  the  eruption  upon  the  intestinal  mucous  membrane. 

English  authors  describe  a  form  of  varicella  which  they  term 
varicella  gangrenosa,  and  which  is  characterized  by  the  appearance  of 
gangrene  in  the  vesicles,  these  spreading  and  manifesting  a  tendency 
to  sloughing,  instead  of  drying  up,  as  in  ordinary  chicken-pox.  The 
gangrenous  vesicles  are  the  seat  of  deep  ulcers,  which  penetrate  the 
skin  and  attack  subcutaneous  structures.  It  is  said  to  be  very  fatal, 
pyaemia  and  exhaustion  resulting,  in  many  cases.  It  seems  that  the 
disease  is  not  confined  to  puuy,  illy-nourished  children,  but  may 
attack  the  robust  aud  well-conditioned.  Epidemic  influences  and 
unsanitary  surroundings  may  be  responsible  for  it.  It  has  never 
been  reported  in  the  United  States,  to  my  knowledge. 

Diagnosis. — The  diagnosis  of  varicella  would  not  be  such  an 
important  matter,  were  it  not  for  the  fact  that  varioloid  and  this 
disease  are  frequently  confounded;  and  such  a  mistake  might  place 
the  practitioner  in  au  awkward  dilemma,  provided  he  diagnosed  a  case 
of  varioloid  as  varicella,  and  caused  the  exposure  of  a  neighborhood 
to  liability  of  small-pox.  And  it  is  a  matter  of  history  that  for  quite 
a  long  time  varicella  was  not  recognized  as  a  separate  disease  at  all, 
but  was  considered  as  a  variation  of  varioloid.  Care  should  be 
exercised,  then,  in  doubtful  cases,  that  the  physician  does  not  jeop- 
ardize his  reputation  by  a  blunder  in  this  direction.  The  imper- 
fectly formed  vesicles  of  varioloid  may  resemble  those  of  chicken- 
pox,  and  confusion  arise,  unless  some  other  important  particulars  of 
development  be  taken  into  consideration.  It  will  be  remembered 
that  the  eruption  of  varicella  appears  at  first  upon  the  upper  part  of 
the  body,  and  spreads  from  there  to  the  face,  while  variola,  like 
small-pox,  appears  first  on  the  forehead  and  face.  The  invasion  stage 
of  varioloid  is  also  more  marked  than  that  of  chicken-pox,  there 
often  being  vomiting,  backache,  headache,  and  considerable  elevation 
of  temperature  ( two  or  three  days  before  the  appearance  of  the  erup- 
tion), while  in  varicella,  if  any  period  of  invasion  be  noticed  at  all, 
it  will  not  continue  more  than  a  day  before  the  appearance  of  the  erup- 
tion. The  age  of  the  person  attacked  also  will  enable  one  to  arrive  at  a 
pretty  positive  conclusion,  for  though  varioloid  might  attack  very  small 
children,  varicella  is  a  disease  that  would  hardly  be  expected  at  all, 


CHICKEN-POX.  127 

to  attack  adults.  An  eruption,  then,  of  the  character  of  that  of 
chicken-pox  found  upon  an  adult  would  suggest  varioloid,  though 
it  would  not  be  positive  proof.  The  maculae  of  varicella  are  soft, 
and  are  seen  to  be  merely  hypersemic  spots  in  the  skin  when  the 
surface  is  put  upon  the  stretch,  while  the  papules  which  first  appear 
iu  varioloid  are  more  deeply  imbedded,  and  impart  a  shotty  feel  to 
the  finger  when  pressure  is  made  upon  them.  Also,  they  develop 
slowly,  the  papular  stage  continuing  three  or  four  days.  It  has 
been  asserted  that  certain  syphilitic  eruptions  resemble  varicella; 
but  the  multiform  character  of  syphilitic  eruptions,  their  chrouic 
course,  and  the  absence  of  pronounced  fever,  ought  to  distinguish 
this  disease  from  varicella,  to  the  most  superficial  observer. 

Prognosis. — Varicella  is  the  most  benign  of  all  the  exanthema- 
tous  fevers.  It  is  so  mild  that  little  need  of  medication  arises  in 
the  majority  of  cases,  though  unpleasant  symptoms  may  appear,  call- 
ing for  treatment.  I  have  never  seen  a  case  which  occasioned  me 
the  least  anxiety,  and  would  consider  that  one  must  have  been 
very  badly  treated  indeed,  if  it  did  not  progress  favorably  from  the 
beginning.  A  few  permanent  cicatrices  may  remain  upon  the  face, 
as  the  result  of  violence  during  the  stage  of  eruption,  but  these  will 
not  be  so  numerous  as  to  constitute  disfigurement,  and  they  will 
occur  in  but  few  cases. 

Treatment. — The  treatment  of  varicella  will  not  be  a  matter 
that  will  be  of  much  moment  to  the  physician,  many  times,  as  his 
services  will  usually  be  required  more  for  diagnostic  purposes  than 
for  treatment.  If  a  febrile  condition  is  found  to  be  present,  with 
restlessness  and  irritability,  a  combination  of  aconite  and  rhus  tox., 
in  water,  in  appropriately  minute  quantity  to  act  as  a  gentle  sedative 
without  disturbing  the  circulation,  will  be  found  serviceable.  Where 
the  vesicles  have  appeared  in  the  mouth,  and  cause  unpleasant  smart- 
ing upon  the  taking  of  food  or  drinks,  minute  doses  of  phytolacca 
and  aconite  will  be  useful.  For  a  child  two  or  three  years  of 
age,  two  or  three  drops  of  Lloyd's  aconite  and  ten  or  fifteen  drops  of 
phytolacca  added  to  four  ounces  of  water,  will  furnish  enough  medi- 
cine, when  a  teaspoonful  is  administered  every  two  hours.  Where 
there  is  marked  periodicity  in  the  fever,  one  or  two  grains  of  arseni- 
afe  of  ijuinia,  3x  trituration,  may  be  given  every  four  hours,  until 
the  periodicity  ceases,  which  will  be  in  two  or  three  days.  Itching 
of  the  skin  may  be  quieted  with  alkaline  baths,  or  the  application  of 
the  following  mixture :  R  Resorcin  one  drachm,  alcohol  one  ounce, 
glycerine  half  an  ounce,  and  water  ten  ounces.  Mix,  and  apply  with 
a  soft  sponge,  or  linen  cloth.  Lar^e  vesicles  upon  the  face  should  be 
emptied  early,  the  openings  being  well  sponged,  to  anticipate  pitting, 


128  SPECIFIC  INFECTIOUS  DISEASES. 

and  prevent  itching,  and  scratching  which  might  result  in  scarring. 
During  the  course  of  the  disease,  an  even  temperature  should  be 
maintained  in  the  room  occupied,  and  the  patient  protected  from 
draughts  of  cold  air.  Physic  should  be  tabooed,  as  well  as  the  use 
of  stimulating  food. 

VHI.  SCARLET  FEVER. 

Synonyms. — Scarlatina;  Scarlet  Bash. 

Definition. — An  acute,  contagious  disease,  characterized  by 
inflammation  of  the  skin  and  mucous  membranes,  accompanied  bv 
an  eruption  of  bright-red  color  (from  which  the  disease  takes  its 
name),  a  high  temperature,  a  tendency  to  destructive  inflammation 
of  the  throat,  and  an  unusual  predisposition  to  nephritis  and  des- 
quamation  of  the  cuticle. 

Etiology. — The  cause  of  scarlet  fever  is  a  specific  infection — 
presumably  a  microorganism,  though  it  has  never  been  isolated. 
It  may  be  communicated  directly,  from  one  affected,  or  through  a 
third  person.  The  epidermis  seems  to  carry  and  preserve  the  poi- 
son for  months  and  even  years,  and  the  disease  is  most  commonly 
disseminated  by  desquamated  particles,  which  find  lodgment  in 
clothing,  carpets,  upholstery,  etc.  Mail-packages,  accidentally  con- 
taining it,  may  convey  the  disease  for  long  distances,  and  travelers 
may  carry  it  in  their  baggage,  from  continent  to  continent.  Another 
medium  of  transmission  is  hair,  in  which  particles  may  become 
lodged,  and  transmitted  from  place  to  place.  Loomis  asserts  that 
an  instance  occurred  under  his  observation  in  which  the  disease  was 
carried  by  a  dog,  from  the  children  of  one  family  to  those  of  another, 
the  animal,  having  been  around  the  infected  children  for  several 
days,  afterward  making  a  single  visit  to  a  neighbor's  house.  The 
breath  of  affected  persons  undoubtedly  contains  the  infective  prin- 
ciple, this  probably  being  usually  the  medium  of  direct  transmission. 

The  danger  to  infection  of  fomites  is  proportionate  to  the  length 
of  time  they  are  exposed  to  the  contagium.  A  member  of  a  family 
where  the  disease  was  prevailing,  or  the  nurse,  would  be  more  lia- 
ble to  convey  it  in  clothing  than  the  physician,  who  would  only 
make  brief  calls.  It  is  rarely  the  case  that  the  disease  is  trans- 
ported by  a  medical  attendant. 

Another  medium  of  conveyance  is  food,  especially  milk,  the  dairy- 
man being  capable  of  communicating  the  disease  to  many  families, 
should  it  occur  in  his  own  household.  Furthermore,  it  is  believed, 
by  some,  that  cattle  may  be  affected  from  it.  It  is  inoculable. 

A  single  attack  of  scarlatina  is  usually  protective  against  subse- 
quent exposure.  The  accounts  we  frequently  hear,  of  several  attacks 
of  scarlatina  in  a  single  individual,  should  be  receieved  with  much 


SCARLET  FEVER  129 

allowance,  as  it  is  common  among  physicians  to  render  a  grossly 
incorrect  diagnosis  between  this  disease  and  rubella.  Many  phy- 
sicians diagnose  rubella,  habitually,  as  scarlatina,  there  being  con- 
siderable resemblance  in  the  general  picture;  and  we  often  hear  of 
scarlet  fever  in  the  neighborhood  when  there  has  been  none  about, 
but  simply  slight  cases  of  rubella.  This  accounts  for  the  assertion 
that  a  child  has  had  the  disease  and  is  protected,  when  it  is  really 
as  susceptible  as  ever  to  scarlatina,  and  falls  a  victim,  on  exposure. 

It  is  essentially  a  disease  of  childhood,  though  adults  may  be 
affected.  Adults,  however,  usually  escape  with  a  mild  attack. 

Pathology. — The  general  tissue-changes  of  fever  are  well  marked 
in  this  disease,  and  hardly  require  special  mention.  There  are  the 
granular  degeneration,  the  loss  of  fibrin  in  the  blood,  the  conges- 
tion of  the  braiu,  spleen,  liver,  and  other  internal  organs,  and  other 
changes  due  to  a  protracted  pyrexia,  which  we  find,  more  or  less,  in 
all  febrile  diseases.  The  skin  and  throat  bear  the  principal  brunt  of 
the  disease,  and  the  results  are  manifested  in  the  anatomical  changes 
which  occur.  Often  the  kidneys  become  involved,  and  the  alterations 
which  attend  and  follow  acute  nephritis  are  manifested  in  these 
organs. 

Sequelce  result  in  destructive  inflammation  of  the  middle  ear, 
inflammation  and  suppuration  of  the  glands  and  cellular  tissue  of 
the  neck,  keratitis,  inflammation  of  the  serous  membranes,  etc. 

The  eruption  may  fairly  be  regarded  as  the  distinguishing  lesion. 
The  skin  becomes  excessively  hyperaemic,  congested,  and  cedematous, 
the  fingers  being  swollen  and  stiff,  this  being  attended  by  serous 
exudation  into  the  rete  Malpighii.  Bapid  cell  proliferation  in  the 
underlying  layers  of  the  epidermis  results,  and  when  the  hypersemia 
subsides  the  epidermis  is  cast  off,  the  exfoliation  being  due  to  the 
excessive  production  of  newly-formed  epidermis  beneath.  During 
the  period  of  hyperaemia,  extravasations  may  occur  in  the  skin. 

The  mucous  membrane  of  the  mouth  and  throat  becomes  congested, 
extravasated,  and  cedematous.  An  abundant  secretion  of  catarrhal 
material  is  usually  poured  out,  forming  a  tenacious  coating  upon 
the  surface  of  the  tonsils  and  fauces,  though  the  parts  may  be  dry 
and  glazed,  instead.  The  color  is  bright  red  at  first,  but  in  several 
cases  the  parts  become  strangulated  and  sloughy,  with  dark  and  livid 
color.  Follicular  sloughing,  or  a  more  general  breaking  down,  may 
invade  the  tonsils  and  adjacent  parts.  The  subcutaneous  tissues  .may 
be  involved  in  suppurative  action,  giving  rise  to  retro-pharyngeal 
abscess,  and  the  connective  tissues  and  cervical  lymphatics  may  be 
invaded,  extensive  slouching  abscesses  resulting,  with  destruction 
of  arterial  twigs,  followed  by  dangerous  hemorrhage.  The  parotid 


10 


130  SPECIFIC  INFECTIOUS  DISEASES. 

and  sublingnal  glands  may  be  affected,  severe  inflammatroy  action 
attending. 

The  kidney  presents  the  characters  of  acute  B right's  disease. 
The  entire  organ  is  congested,  extravasations  occurring  here  and 
there.  The  glomeruli  are  altered,  and  the  convoluted  tubes  are 
sometimes  found  to  be  the  seat  of  croupous  inflammation,  this 
involving  the  entire  length  of  the  tubuli  uriniferi.  All  the,  charac- 
teristics of  severe  acute  nephritis  may  be  observable. 

Symptoms. — The  period  of  incubation  varies  from  a  few  hours 
to  a  week,  the  time  usually  being  six  days.  It  is  difficult  to  describe 
the  symptoms  of  this  disease  understaudingly  in  few  words,  as  there 
is  a  great  diversity  of  conditions,  depending  upon  the  severity  of 
the  disease,  the  character  of  the  epidemic,  the  parts  rucst  violently 
affected,  and  other  states  which  modify  or  aggravate  the  character 
of  the  attack,  in  some  particular  or  manner.  I  will  here  describe  the 
symptoms  of  an  average  case,  and  afterward  endeavor  to  discrimi- 
nate between  some  of  the  most  marked  classes  of  cases.  The  dis- 
ease may  be  divided  for  description  into  three  stages,  naturally 
marked  by  their  peculiar  symptoms,  viz.,  a  stage  of  invasion,  a 
stage  of  eruption,  and  a  stage  of  desquamation. 

The  invasion  stage  begins  abruptly.  A  chill  is  followed  by  high 
fever,  though  the  temperature  rises  progressively  through  this  stage 
until  the  rash  appears.  The  chill  is  usually  marked,  sometimes 
amounting  to  a  rigor,  and  in  small  children  it  may  be  attended  by 
convulsions  or  coma.  Rapidity  of  pulse  is  characteristic  of  this  dis- 
ease as  an  eruptive  fever,  130  to  140  beats  per  minute  not  being  an 
unfrequent  rate.  Vomiting  is  almost  a  constant  symptom,  the  ejec- 
tion beiug  forcible  and  projectile  in  character,  and  the  gastric  irri- 
tation difficult  to  control.  Burning  and  prtcJding  sensations  in  the 
skin  and  throat,  with  stiffness  of  the  muscles  of  the  neck,  are 
early  symptoms,  and  the  skin  imparts  the  sensation  of  pungent  heat 
to  the  hand  of  the  observer.  Headache  is  marked,  being  aggravated 
by  the  vomiting,  and  restlessness  and  delirium  may  occur,  even  dur- 
ing the  pyrexia  of  this  stage.  In  one  or  two  days,  usually  in  about 
thirty-six  hours,  the  rash  appears,  and  the  stage  of  invasion  comes 
to  an  end. 

The  eruption  stage  usually  begins  with  the  temperature  at  103°  or 
104°,  but  this  soon  rises  to  105°  F.,  or  more.  The  vomiting,  pungent 
heat  of  the  skin,  throat  mischief,  and  nervous  symptoms,  soon 
become  aggravated;  the  patient  vomits  more  frequently,  is  very 
restless,  and  often  the  delirium  increases.  The  rash  first  appears 
on  the  neck,  breast,  and  back,  rapidly  spreading  over  the  entire  sur- 
face— except  an  area  about  the  mouth,  where  it  seldom  appears — thus 


SCARLET  FEVEK.  131 

constituting  a  rather  distinctive  feature  of  the  disease,  the  lips 
being  pallid,  the  contrast  with  reddened  cheeks  thus  being  quite 
striking.  The  eruption  first  appears  as  scarlet  points  (uot  elevated 
above  the  surface)  which  gradually  spread  until  they  coalesce,  the  bor- 
ders being  of  lighter  color  than  the  center.  They  then  coalesce,  form- 
ing au  even  pinkish  or  scarlet  ground,  dotted  with  minute  bright  red 
points.  The  rash  may  or  may  not  be  confluent,  it  often  appearing 
in  isolated  patches,  instead  of  being  evenly  spread  over  the  surface, 
it  then  being  found  on  the  chest,  abdomen,  neck,  cheeks,  and  inner 
aspect  of  the  arms  and  thighs.  It  disappears  on  pressure,  and  after 
the  fourth  day  a  letter  may  be  traced  upon  the  surface,  to  remain 
until  all  its  outline  is  completed,  before  fading  out.  This  is  a  char- 
acteristic peculiar  to  scarlatina,  rashes  similar  in  appearance  hardly 
leaving  so  permanent  a  line.  The  color  of  the  rash  may  vary,  it 
being  scarlet  in  some  cases,  in  others  pinkish,  and  in  still  others  of 
a  dusky  or  purplish  hue.  The  last  characteristic  marks  grave  cases, 
and  the  danger  is  in  proportion  to  the  depth  of  the  purplish  tint  of 
the  eruption.  Miliaria  often  appear  about  the  neck  and  chest,  and 
the  papillsB  become  prominent  in  some  cases  (cutis  anserina),  while 
petechise  mark  the  points  of  minute  extravasations.  By  the  third 
or  fourth  day  the  eruption  has  reached  its  full  development,  and  it 
begins  to  fade  by  the  fifth.  The  skin  is  now  found  to  be  cedematous, 
the  hands  and  fingers  manifesting  the  effusion  most  markedly,  the 
fingers  being  swollen  and  clumsy  from  the  subcutaneous  oedema, 
By  the  tenth  day  the  eruption  has  usually  disappeared. 

During  the  eruptive  stage  the  general  symptoms  of  the  invasion 
stage  are  all  aggravated.  Intense  thirst  is  present.  The  vomiting 
often  disappears  after  the  first  day,  though  it  may  continue  in  an 
aggravated  form,  especially  if  the  disease  has  thus  far  been  clum- 
sily treated.  The  tongue,,  which  in  the  start  was  covered  with  a  white 
coating,  except  at  the  tip  and  edges,  which  were  reddened,  now  cleans 
and  presents  a  deep  red  appearance,  with  elevated  papillae  resem- 
bling a  ripened  strawberry  in  its  aspect.  It  is  moist  in  moderate 
cases,  but  in  more  severe  ones  it,  as  well  as  the  mouth  and  throat, 
becomes  dry  and  parched,  tlie  mucous  membrane  presenting  a  glazed 
appearance.  Later,  the  tongue  may  become  brown  and  cracked. 
The  throat  now  becomes  decidedly  hypersemic,  the  soft  palate, 
uvula,  pillars  of  the  fauces,  and  often  the  posterior  surface  of  the 
pharynx,  presenting  a  bright  red  appearance,  the  parts  being  swol- 
len and  cedematous.  The  oedema  may  be  so  marked  that  the  uvula 
and  tonsils  meet,  closing  the  fauces.  "When  moist,  there  is  a  tena- 
cious secretion — exudate  from  the  follicles  of  the  tonsils — adhering 
about  the  openings  of  the  follicles,  or  spread  over  the  inflamed 


132 


SPECIFIC  INFECTIOUS  DISEASES. 


mucous  membrane.  In  some  cases  the  secretion  is  absent,  the 
mucous  membrane  being  dry,  and  the  exudation  retained,  forming 
abscesses  in  the  follicles.  Sometimes  retro-pharyngeal  abscesses 
may  result  from  the  inflammatory  action.  Ulceration  follows  the 
eruptive  stage  in  severe  cases  usually,  though  in  very  bad  ones  it 
may  occur  earlier,  follicular  ulceration  being  the  least  extensive  form, 
though  larger  areas  may  be  invaded.  The  patient  complains  of 
severe  pain  upon  swallowing,  the  voice  is  nasal  in  character,  the 
neck  is  stiffened  and  swollen,  the  cervical  glands  are  knotted,  hard, 
and  tender,  and  extensive  inflammation  of  the  connective  tissue  may 
portend  deep  and  dangerous  abscesses  in  the  cervical  region. 

The  temperature  of  the  erup- 
tion stage  usually  rises  until  the 
rash  is  fully  developed,  when  it 
gradually  falls,  a  crisis  generally 
occurring  when  it  begins  to  fade, 
the  temperature  falling  to  nor- 
mal. A  slight  rise  in  tempera- 
ture after  this  is  not  unexpected, 
the  cutaneous  changes  occasion- 
ing more  or  less  symptomatic 
fever,  an  elevation  of  a  degree 
and  a  half  or  two  degrees  con- 
tinuing until  the  eruption  has' 
faded  and  desquamation  has 
well  begun. 

The  pulse  continues  rapid,  as 
long  as  pyrexial  action  exists, 
rapidity  being  a  characteristic,  the  rate  often  reaching  as  high  as 
160  per  minute  during  the  fastigium. 

Secretion  from  the  skin  and  kidneys  is  arrested,  the  urine  being 
scanty  and  highly  colored,  and  usually  containing  excess  of  bile  pig- 
ment, and  a  sediment  of  lithates,  or  free  uric  acid. 

The  desquamative  sfage  begins  a  few  days  after  the  rash  has  dis- 
appeared, though  there  is  no  regularity  about  the  beginning  of  this 
period.  Sometimes  it  begins  before  the  rash  has  entirely  faded,  and 
again  it  may  be  weeks  before  desquamation  will  be  noticed.  The 
more  intense  the  eruption  the  earlier  desquamation  usually  begins, 
for  the  pronounced  changes  in  the  epidermis  tend  to  a  prompt  cast- 
ing off  of  the  superficial  layer.  In  milder  cases,  the  casting-off  pro- 
cess is  liable  to  be  postponed  for  a  long  time — even  four  or  five 
weeks.  Prior  to  the  peeling  process,  the  epithelium  presents  a  dry, 
wrinkled  appearance,  after  which  it  begins  to  break  away  in  fine, 


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SCARLET  FEVER.  133 

bran-like  scales.  Over  the  neck,  breast,  and  other  parts  where  the 
skin  is  delicate,  it  separates  in  this  way;  but  where  it  is  thick,  as 
iu  the  palms,  and  on  the  soles,  the  epidermis  may  come  away  in 
large  patches,  even  the  entire  surface  of  the  palm  being  cast  off  in  a 
single  patch,  in  some  instances.  The  period  of  desquamation  com- 
moiily  la^ts  ten  days  or  two  weeks,  but  it  may  continue  for  a  much 
longer  time  in  some  instances,  relapses  of  dssquamation  seeming  to 
sometimes  occur,  the  scaliness  lingering  about  the  fingers  and  toes. 
It  is  asserted,  by  good  authority,  that  the  infection  lingers  until  the 
last  scale  of  epidermis  has  been  cast  off.  During  this  period,  the 
pulse  is  abnormally  slow,  falling  to  65  per  minute  in  many  instances, 
and  the  temperature  is  depressed  to  subnormal  The  skin  now  lacks 
its  normal  covering  and  protection,  and  the  patient  is  easily  affected 
by  a  cool  temperature,  or  sudden  changes  of  air. 

The  great  variation  in  the  symptoms  of  this  disease,  has  led  to 
its  division  by  authors,  for  description,  into  three  varieties,  viz., 
scarlatina  simplex,  scarlatina  anginosa,  and  scarlatina  maligna.  These 
forms  are  apt  to  occur  epidemically,  the  simple  form  sometimes 
marking  every  case,  while  the  more  severe  anginosa  form  may  pre- 
vail in  another.  Occasionally,  the  malignant  form  appears  as  a 
scourge,  attended  by  frightful  fatality. 

In  scarlatina  simplex,  the  symptoms  are  all  of  a  mild  character. 
The  chill  is  slight  and  the  reaction  mild,  the  temperature  not  reach- 
ing more  than  102°  or  103°  F.,  the  eruption  coming  out  in  patches 
(with  little  oedema  of  the  skin)  of  bright  scarlet  or  pink  color. 
The  soreness  of  the  throat  is  not  severe  and  passes  off  early,  the 
fever  declining  in  a  day  or  two,  convalescence  thus  being  soon  estab- 
lished. Desquamation  is  slight,  when  compared  with  that  of  the 
other  forms.  Though  this  variety  is  treacherous,  the  prognosis  is 
usually  favorable.  Still,  each  case  demands  careful  management. 

Scarlatina  anginosa  appears  in  more  severe  form.  The  chill  is 
marked,  the  febrile  reaction  is  high,  and  there  is  vomiting  and  head- 
ache upon  the  appearance  of  the  eruption,  which  becomes  confluent. 
The  throat  symptoms  are  quite  severe,  though  not  extremely 
destructive,  and  the  temperature  reaches  105°  to  106°,  the  patient 
frequently  being  delirious  an  1  restless,  or  suffering  with  thirst,  head- 
ache, ami  other  marked  discomfort.  Late  in  the  course  of  this  form, 
ulceration  of  the  tissues  of  the  throat  may  occur,  but  it  does  not 
seem  of  that  active  kind  which  attacks  the  throat  in  malignant  scar- 
latina as  early  as  the  fifth  or  sixth  day.  In  this  form  the  eruption 
does  not  fade  entirely  before  the  tenth  or  twelfth  day,  and  all  the 
stages  are  more  protracted  than  in  the  first  variety.  Sometimes  a 
persistently  high  temperature  may  attend  this  form,  depending  upon 


134  SPECIFIC  INFECTIOUS  DISEASES. 

nephritis  and  other  complications,  which  are  rare  in  scarlatina  sim- 
plex. Desquamation  is  a  marked  feature  of  this  form,  the  entire 
palm  of  the  hand  or  sole  of  the  foot  sometimes  peeling  away  in 
a  single  patch, 

Scarlatina  maligna,  like  the  other  forms,  usually  occurs  in  epi- 
demics. It  is  markedly  fatal,  from  twenty  to  fifty  per  cent  of  the 
cases  terminating  fatally,  in  different  epidemics.  Two  varieties  of 
scarlatina  maligna  may  be  described,  the  nervous  and  the  sloughing. 
In  the  nervous  variety  the  cerebro-spinal  system  seems  profoundly 
involved  from  the  very  beginning,  the  patient  passing  into  the  m;>st 
violent  symptoms  at  once.  The  chill  may  not  be  remarkable,  but 
the  vomiting  is  extreme  from  the  commencement,  often  attended  by 
purging.  The  temperature  rises  to  107°  or  108°  R,  early,  convulsions, 
violent  delirium,  or  coma,  quickly  following.  The  onset  of  the  dis- 
ease seems  overwhelming,  and  a  condition  of  collapse  is  liable  to 
be  reached  by  the  fifth,  or  sixth  day,  the  eruption  perhaps  never 
appearing.  By  this  time,  the  breathing  is  rapid  and  shallow,  the 
pulse  fluttering,  the  countenance  haggard,  and  the  skin  clammy,  as 
the  patient  lies  in  a  state  of  coma.  Dissolution  rapidly  follows.  In 
another  form,  the  throat  mischief  is  excessively  developed  by  the 
fifth  or  sixth  day,  the  fauces  becoming  remarkably  swollen  and  ten- 
der, and  deglutition  very  difficult  and  painful.  The  throat  is  found 
deep  red  or  dark  purple  in  color,  and  dotted  with  patches  of  ashy- 
gray  exudation  with  blackened  edges.  The  lymphatic  glands  at  the 
angles  of  the  jaw  and  the  connective  tissues  around  them  are  swol- 
len and  inflamed,  marking  the  sites  of  subsequent  sloughing.  The 
face  is  livid  and  haggard;  the  pulse  is  quick,  feeble,  and  fluttering; 
sordes  appear  upon  the  teeth  and  lips;  the  tongue  is  dry,  brown, 
and  cracked;  the  breath  is  offensive  and  putrid;  an  ichorous  dis- 
charge exudes  from  the  nostrils,  and  soon  rapid  and  wide  destruc- 
tion of  tissue  occurs,  involving  the  soft  parts  about  the  fauces,  and 
even  perforating  the  skin  from  the  inside.  (Edema  of  the  glottis 
may  now  occasion  suffocation,  hemorrhage  from  destruction  of 
important  vessels  may  exanguinate  the  patient,  or  pyaemia  may 
slowly  sap  the  vital  forces.  Such  cases  are  almost  certain  to  termi- 
nate fatally. 

Scarlatina  is  a  treacherous  disease,  and  the  mildest  case,  there- 
fore, is  often  fraught  with  danger.  There  are  always  liable  to  arise 
complications,  which  may  bring  about  a  fatal  termination.  In  some 
apparently  mild  epidemics,  where  the  scarlatinal  attacks  seem  only 
that  of  the  simple  form,  nephritis  will  follow  or  attend  the  desquam- 
ative  process,  and  anasarca  aud  albumiuuria  prove  fatal.  Or  inflam- 
mation of  the  middle  ear  may  arise  during  the  course  of  an  appar- 


SCAELET  FEVER.  135 

ently  mild  attack  of  the  disease,  and  terminate  in  symptoms  of 
meningitis.  Other  serious  complications,  such  as  typhoid  symptoms, 
may  arise,  where,  in  the  beginning,  and  even  as  late  as  the  termina- 
tion of  the  eruptive  stage,  the  disease  is  apparently  of  the  mildest 
character.  I  will  briefly  consider  a  few  of  the  more  common  com- 
plications and  sequelae  of  this  affection. 

Complications  and  Sequelae. — Probably  the  most  frequent 
complication  is  that  which  arises  from  kidney  mischief.  The  first 
symptom  which  will  attract  attention  here  usually,  will  be  anasarca. 
The  child  may  appear  to  be  doing  well  and  convalescing  properly, 
when  suddenly  it  is  observed  that  a  marked  dropsical  condition  has 
arisen.  This  is  during  or  immediately  following  the  desquamative 
period.  The  disposition  of  many  is  to  ascribe  this  to  sudden  chill- 
ing of  the  surface  when  the  skin  is  poorly  protected  by  epidermis; 
and  this  may  have  a  bearing,  but  it  seems  that  certain  epidemics  are 
attended  by  a  predisposition  to  such  a  complication.  As  such  cases 
have  been  almost  unknown  in  my  practice,  I  am  disposed  to  ascribe 
them  to  too  heroic  treatment  in  the  beginning;  to  the  use  of  too 
active  diaphoretics  or  diuretics — more  especially  diuretics — which  set 
up  an  irritation  which  the  natural  tendency  of  the  disease  carries 
forward  to  an  actual  nephritis.  In  all  cases  of  scarlatina,  it  is  best 
to  avoid  unnecessary  stimulation  of  the  kidneys;  and  it  is  difficult 
for  me  to  understand  why  they  should  be  stimulated  at  alL  Consti- 
tutional symptoms,  such  as  headache,  vomiting,  restlessness,  and  a 
return  of  pyrexia,  the  temperature  rising  two  or  three  degrees,  but 
the  pulse  becoming  markedly  slow  and  full,  now  attend.  The  urine 
will  be  found  to  contain  albumen  and  casts,  as  well  as  blood-corpus- 
cles. Sometimes  hematuria  will  be  present  In  two  or  three  days, 
in  favorable  cases,  the  fullness  of  the  tissues  will  gradually  subside, 
the  swelling  of  the  hands,  feet,  abdomen,  and  tissues  generally,  will 
become  less  marked,  the  patient  will  brighten  up  from  the  depres- 
sion resulting  from  this  condition,  the  appetite  will  improve,  the 
urine  clear  up,  and  recovery  go  on  uninterruptedly.  In  unfavora- 
ble cases,  the  pulse  becomes  more  feeble  but  increased  in  rapidity, 
the  anasarca  increases,  the  patient  passes  into  a  condition  of  coma 
or  convulsions,  and  death  terminates  the  case. 

Inflammation  of  the  serous  membranes  is  another  sequel  of  scarla- 
tina. Among  these,  the  part  most  liable  to  be  involved  is  the  endo- 
cardium, and  fatal  endocarditis  is  liable  to  be  the  final  result. 
Pleuritis,  peritonitis,  syuovitis,  sometimes  going  on  to  suppurative 
arthritis,  but  more  commonly  to  the  joint  symptoms  of  inflamma- 
tory rheumatism,  are  sequelae  of  this  disease. 

A   very    serious    complication    is   diphtheria,  which  occasionally 


136  SPECIFIC  INFECTIOUS  DISEASES. 

occurs,  and  is  very  liable  to  prove  fatal.  Unlike  the  complications 
already  named,  which  are  apt  to  appear  late  in  the  course  of  the 
disease,  this  affection  may  arise  at  any  time,  though  it  usually 
occurs  during  the  period  of  desquamation.  The  symptoms  do  not 
differ  from  those  of  the  uncomplicated  disease,  except  that  char- 
acteristic exudation  and  marked  depression  are  noticeable.  A  fatal 
course  is  almost  invariably  run  when  this  complication  arises,  the 
already  debilitated  condition  of  the  patient  offering  feeble  founda- 
tion for  successful  treatment. 

Among  other  complications  which  occasionally  attend  may  be 
named  eye  affections,  such  as  keratitis,  retinitis,  and  complete  loss 
of  vision.  Also  anemia,  spinal  disease,  paralysis  of  single  nerves, 
deafness,  chorea,  epilepsy,  valvular  disease,  and  chronic  albuminuria. 

Diagnosis. — The  diagnosis  of  scarlatina  ought  not  to  be  diffi- 
cult, yet  there  is  often  confusion  and  mistake  in  identifying  it. 
There  ca-i  be  little  excuse  for  confounding  it  with  measles,  for  in 
that  disease  the  catarrhal  symptoms  are  so  prominent,  in  the  major- 
iry  of  cases,  that  they  cannot  be  mistaken,  while  they  are  absent  in 
scarlatina,  especially  in  the  beginning.  The  eruption  of  measles 
appears  first  on  the  face,  while  that  of  scarlatina  shows  first  on  the 
neck  and  breast.  The  fever  of  scarlatina  persists  after  the  appear- 
ance of  the  eruption,  while  in  measles,  it  falls.  The  catarrhal  fea- 
tures of  measles,  however,  constitute  such  a  distinctive  character 
that  there  is  hardly  a  possibility  of  confounding  it  with  scarlatina. 

Confluent  small-pox  may  at  first  resemble  scarlatina,  so  far  as  the 
eruption  is  concerned,  though  the  "shotty"  feel  of  the  papules  will 
here  be  an  aid  in  diagnosis,  and  the  first  vesicle  will  settle  the 
question. 

Rubella  (roseola)  'is  the  disease  which  is  most  commonly  mis- 
taken for  scarlatina,  and  many  physicians  seem  not  to  know  that 
such  a  disease  as  rubella  exists,  their  diagnosis  of  all  such  cases 
being  that  of  scarlatina.  There  is  a  great  deal  of  resemblance 
between  rubella  and  mild  cases  of  scarlatina  (scarlatina  simplex), 
though  it  would  be  almost  impossible  for  an  epidemic  of  mild  scar- 
latina to  occur  without  the  occasional  cropping  out  of  some  of  the 
sequelae,  such  as  anasarca,  otitis,  etc.,  while  these  are  almost  never 
known  in  rubella.  The  constitutional  symptoms  of  rubella  are  also 
out  of  proportion  to  those  of  scarlatina,  when  the  comparative  sever- 
ity of  the  throat  symptoms  are  considered.  In  roseola,  also,  there 
is  much  less  permanency  of  the  white  line  left  when  the  finger  is 
drawn  over  the  skiu,  than  in  scarlatina.  The  period  of  desquama- 
tion in  roseola  is  not  marked,  and  only  a  slightly  branny  scaling 
occurs,  and  seldom  ever  the  large  patches  which  are  cast  off  from 


SCARLET  FEVER.  137 

the  palms  and  soles  in  scarlatina,  though  such  a  result  sometimes 
happens. 

Cases  of  malignant  scarlatina  may  occur  in  which  there  is  no 
eruption  before  death,  but  the  presence  of  a  prevailing  epidemic  will 
readily  point  out  the  character  of  the  disease.  It  is  not  probable 
that  there  will  be  any  confusion  in  the  diagnosis  between  diphtheria 
and  this  disease,  the  ashen-gray  exudation  and  marked  prostration 
of  diphtheria,  without  the  heat  of  the  skin  which  marks  scarlatina, 
serving  to  point  out  the  difference. 

Prognosis. — Scarlatina  is  a  treacherous  disease,  and  the  prog- 
nosis should  always  be  guarded.  After  a  few  cases  have  been  seen 
throughout  their  course,  and  the  epidemic  has  been  shown  to  be 
mild,  of  course  a  guardedly  favorable  prognosis  may  be  rendered, 
where  an  epidemic  of  scarlatina  simplex  is  prevailing,  and  where  the 
throat  affection  is  slight  and  constitutional  symptoms  are  mild,  the 
eruption  appearing  within  forty-eight  hours  from  the  commence- 
ment. The  more  abrupt  the  onset,  such  as  vomiting,  delirium,  etc., 
the  darker  the  eruption,  and  the  more  severe  the  throat  symptoms  at 
an  early  stage  of  the  disease,  the  more  doubtful  the  prognosis.  Age 
exercises  considerable  influence,  infants  and  children  up  to  the  age 
of  five  years  being  the  most  unfavorable  subjects.  Beyond  this  age, 
up  to  adult  life,  the  prognosis  is  better.  Adults  affected  with  car- 
diac or  renal  disease,  and  pregnant  women,  are  unfavorable  subjects. 
An  epidemic  may  develop  some  peculiarity,  such  as  malignancy,  ana- 
sarca,  etc.,  the  knowledge  of  which  will  have  an  important  bearing 
upon  the  prognosis  during  that  season. 

Treatment. — Prophylaxis. — As  this  is  a  highly  contagious  dis- 
ease, it  is  important  that  patients  affected  with  it,  as  well  as  those 
who  have  been  exposed,  should  be  strictly  secluded  from  those  not 
infected.  Scarlet-fever  patients  should  be  confined  to  the  sick  room 
until  desquamation  has  completely  ceased;  and  as  long  a  time  as 
three  weeks  should  be  allowed  for  this,  after  the  period  of  desquama- 
tion has  begun.  Unnecessary  furniture  should  be  removed  from  the 
room,  thus  leaving  as  little  material  to  act  as  fomites  as  possible. 
The  clothing  aud  secretions  of  the  patient  should  be  thoroughly 
disinfected,  as  in  typhoid  fever,  and  during  the  period  of  desquama- 
tion, measures  should  be  taken  to  prevent  the  dissemination  of  par- 
ticles of  dry  cuticle.  These  will  consist  in  the  use  of  warm  sponge 
baths  and  fatty  inunction,  or  the  use  of  olive  oil  upon  the  skin  after 
sponging.  Nurses  and  others  much  about  the  sick  room  should  not 
have  intercourse  with  those  who  have  not  been  exposed,  until  after 
the  period  of  desquamation  has  passed,  and  their  clothing  should  be 
carefully  disinfected  before  being  worn  in  public.  The  apartment 


138  SPECIFIC  INFECTIOUS  DISEASES. 

occupied  should  be  disinfected  and  aired,  with  the  windows  open  for 
several  weeks  prior  to  further  occupancy.  The  funerals  of  those  dying 
with  this  disease  should  be  private,  that  danger  of  spreading  the 
infection  in  this  way  may  be  avoided. 

Medicines  have  been  recommended  to  prevent  the  development  of 
the  disease  after  exposure,  or  to  lessen  its  severity.  Belladonna 
has  long  been  recommended  as  one  of  these,  but  there  is  much  dis- 
agreement as  to  its  virtue.  I  think  it  exerts  little  if  any  formida- 
ble influence  in  genuine  scarlatina.  Arsenic  has  been  recommended 
by  some  who  deny  the  virtues  of  belladonna.  It  should  be  admin- 
istered in  minute  doses  of  Fowler's  solution  in  such  case,  and  its 
use  should  be  begun  as  long  as  possible  beforehand.  Echinacea 
promises  more,  to  ward  off  the  severe  forms  of  the  disease,  than  all 
other  remedies ;  for,  though  it  may  not  be  considered  prophylactic 
in  the  strict  sense  of  the  word,  it  fortifies  the  blood  against  sepsis, 
the  tissues  against  phagedena,  and  the  cerebro-spinal  centers  against 
acute  morbid  changes.  In  malignant  scarlatina,  all  susceptible  per- 
sons who  have  been  exposed  should  take  three  or  four  doses  of  this 
medicine  per  day,  one  drop  for  each  year  of  age  being  a  good  rule 
to  follow  in  dosage. 

The  medicinal  treatment  of  scarlatina  cannot  be  reduced  to  a 
routine  practice.  So  many  varying  conditions  confront  us  in  every 
epidemic,  that  individualization  of  cases  in  treatment  will  be  the 
only  successful  plan  to  pursue.  However,  a  few  suggestions  may 
aid  the  practitioner  to  meet  the  various  conditions  which  arise. 
The  principal  requisite  is  a  knowledge  of  the  proper  application  of 
dynamical  therapeutics. 

In  the  treatment  of  scarlatina  simplex  little  is  required,  except  the 
use  of  aconite  and  phytolacca,  in  small  doses,  frequently  repeated,  to 
control  the  fever  and  throat  irritation,  thus  guarding  against  sequelae 
and  complications,  as  the  disease  progresses.  During  exfoliation 
and  convalescence,  the  patient  should  wear  flannels  next  the  skin, 
and  the  surface  should  be  anointed  with  lard  twice  a  week,  to  pro- 
tect the  denuded  surface  against  sudden  chilling,  thus  acting  as  a 
safeguard  against  nephritis  and  other  complications.  Bathing  must 
be  avoided  for  several  weeks.  The  diet  should  be  light  and  assim- 
ilable, a  liquid  diet  taxing  the  throat  the  least  Halted  milk  here 
serves  a  valuable  purpose.  The  dose  of  aconite  will  vary  from  one 
to  five  drops  in  four  ounces  of  water;  dose,  a  teaspoonful  every  hour, 
amount  depending  upon  the  age.  If  an  active  agent  like  Lloyd's 
aconite  be  used,  care  must  be  observed  that  the  dose  be  not  so  large 
as  to  embarrass  the  vital  processes.  Convalescence  is  a  protracted 
period  in  recovery  from  scarlatina,  and  too  much  care  cannot  be 


SCARLET  FEVER.  139 

taken  now,  as  it  is  the  most  critical  time  of  scarlatina  simplex,  and 
a  critical  period  in  all  other  forms  of  the  disease  as  well. 

The  treatment  of  scarlatina  anginosa  will  demand  the  employment 
of  a  wider  range  of  remedies.  The  febrile  action  here  is  so  high,  and 
the  cutaneous  irritation  so  marked,  that  aconite  does  not  supply  the 
demand  for  a  prouounced  sedative.  Where  there  is  not  the  urgent 
gastric  symptoms,  manifested  by  nausea  and  vomiting,  the  most 
acceptable  sedative  is  jaborandi,  -which  lowers  the  temperature, 
imparts  a  cooling  influence  to  the  cutaneous  surface,  and  controls 
the  irritation  of  the  fauces,  to  considerable  extent.  Sometimes, 
however — indeed  often — we  shall  be  obliged  to  dispense  with  this 
agent,  on  account  of  the  nausea  and  vomiting,  and  depend  upon  aco- 
nite and  rhus  tax.  Where  jaborandi  is  admissible,  I  add  from  one  to 
two  drachms  of  the  specific  medicine  to  four  ounces  of  water,  and 
give  a  teaspoonful  every  hour,  until  the  eruption  is  well  out,  and 
until  the  fever  has  begun  to  decline.  Where  the  gastric  irritation  is 
marked,  nothing  will  do  better,  usually,  than  a  combination  of  minute 
doses  of  aconite  and  rhus,  though  sometimes  a  resort  to  bismuth, 
peach-lark  frfusion,  ipecac,  etc.,  will  answer  better.  However,  a  very 
certain  indication  for  rhus  tox.  is  the  "strawberry  tongue,"  and  here 
we  almost  universally  have  it.  The  throat  symptoms  are  always 
severe  here,  and  will  occupy  considerable  of  our  attention.  Our 
sedatives  will  assist  some  in  relieving  the  tumefaction  and  pain,  but 
we  must  prescribe  something  still  more  positive.  Phytolacca  and  ech- 
inacea, in  combination,  will  here  be  found  to  serve  an  excellent  pur- 
pose. Half  a  drachm  of  specific  phytolacca  and  two  drachms  of 
specific  echinacea  in  four  ounces  of  water,  for  a  child  five  years  of 
age,  will  not  be  too  strong.  Of  this  we  may  administer  a  teaspoon- 
ful every  half  hour,  in  severe  cases,  until  relief  follows.  Often, 
much  benefit  may  be  obtained  by  using  a  spray  of  echinacea,  one 
part  to  four  of  water.  Where  there  is  dryness,  with  much  burning 
and  pain,  it  affords  considerable  relief.  Sometimes  a  better  remedy, 
used  as  a  spray,  is  a  drachm  of  essence  of  peppermint  to  an  ounce 
of  water  to  which  has  been  added  ten  drops  of  carbolic  acid.  To 
assist  the  action  of  the  sedative  and  other  treatment  in  quieting 
irritation  and  restlessness,  lowering  the  temperature,  etc.,  the  fre- 
quent application  of  warm  alkaline  baths  is  advisable.  Cold  water  is 
not  so  good  in  scarlet  fever,  for,  while  it  affords  temporary  relief, 
there  is  some  doubt  about  the  advisability  of  applying  cold  water 
where  the  skin  has  been  subjected  to  so  much  debilitating  influ- 
ence. Local  applications  to  the  throat  may  or  may  not  amount  to 
much.  One  thing  is  certain,  however,  they  afford  comfort  to  patient 
and  friends,  in  that  something  is  being  done  in  this  direction,  and 


140  SPECIFIC  INFECTIOUS  DISEASES. 

should  not  be  omitted.  The  throat  may  be  swathed  with  cloths 
wruug  out  of  vinegar  and  water,  or  a  solution  of  hydrochlorate  of 
ammonium,  half  an  ounce  of  the  salt  to  a  pint  of  water.  Fatty 
inunction  over  the  surface  of  the  body  is  an  important  measure  after 
the  stage  of  desquamation  has  begun,  as  it  lessens  the  liability  to 
serious  complications,  and  fortifies  the  skin  against  sudden  chilling. 
Where  there  is  extension  of  the  inflammation  alon^  the  eustachian 
tube  to  the  middle  ear,  pulsntilla  and  piper  methysticum  are  valuable 
agents  to  prescribe — ten  or  twenty  drops  of  pulsatilla  and  ten  or 
fifteen  drops  of  piper  methysticum  to  four  ounces  of  water;  dose,  a 
teaspoouful  every  three  hours.  In  persistently  elevated  temperature, 
where  the  ordinary  sedative  treatment  fails,  the  talicylate  of  ammo- 
nium will  be  found  an  excellent  resort,  where  the  stomach  will  retain 
it  During  convalescence,  a  subnormal  temperature  is  a  common 
condition,  and  will  call  for  echinacea,  arseniate  of  quinia  3x,  nitro- 
glycerine, or  sometimes,  small  doses  of  sulphate  of  quinia. 

The  malignant  form  of  scarlatina  presents  us  with  the  class  of 
cases  pronouncedly  demanding  echinacea,  when  the  nervous  phenom- 
ena are  marked.  Where  vomiting  is  persistent,  and  the  medicine 
cannot  be  retained  in  the  stomach,  an  effort  should  be  made  to 
derive  its  effects  by  hypodermic  means.  Subcutaneous  injections  of 
the  drug  may  be  made,  and  its  effects  obtained,  even  though  the 
stomach  will  not  retain  it.  Where  the  tongue  is  heavily  coated 
from  the  beginning,  a  thorough  emetic  will  prepare  the  way  for 
other  treatment  and  interrupt  the  force  of  the  disease,  in  a  great 
measure.  Sometimes  the  hypodermic  use  of  Aulde's  nuclein  may  be 
of  service  here.  The  phagedenic  form  will  be  much  modified  by  free 
doses  of  echinacea,  administered  during  an  early  stage,  and  contin- 
ued throughout  the  course  of  the  disease.  Comatose  conditions  may 
be  benefited  with  small  closes  of  belladonna,  though  baptisia  or  ech- 
inacea should  constitute  a  large  part  of  the  internal  treatment  in 
this  ease.  Wbere  extensive  sloughing  occurs,  nothiug  will  do  better 
as  a  local  application  than  echinacea,  one  part  to  three  of  water, 
applied  frequently.  Burrowing  ulcers  may  be  syringed  with  it,  the 
throat  may  be  gargled  with  it,  and  cloths  saturated  with  it  may  be 
kept  bound  over  the  external  surface. 

Anasarca  will  suggest  the  use  of  apocyuum,  convaUaria  majalis,  or 
digitalis.  Febrile  conditions  will  here  be  met  appropriately  with 
jaborandi.  Sometimes  an  active  hyilrogogue  cathartic  will  assist  in 
reducing  the  swelling,  and  diverting  renal  irritation.  Vapor  baths 
are  applicable  to  this  condition,  and  alone  will  often  succeed 
in  removing  the  morbid  accumulation  and  relieving  the  renal 
obstruction. 


MEASLES.  141 

Many  other  sequelae  may  arise  which  will  require  attention  long 
after  the  termination  of  the  disease  proper,  and  they  therefore  do 
not  come  under  this  department. 

IX.  MEASLES. 

Synonyms. — Bubeola;  Morbilli. 

Definition. — An  acute,  contagious  disease,  characterized  by  an 
eruption  which  appears  on  the  fourth  day,  preceded  and  accompa- 
nied by  marked  catarrhal  symptoms  notably  affecting  the  bronchial 
tubes,  and  a  fever  of  moderate  height. 

Etiology. — Measles  is  a  highly  contagious  disease,  and  it  is  not 
probable  that  it  ever  arises  spontaneously.  The  breath  is  supposed 
to  contain  the  elements  of  infection,  at  least  the  catarrhal  elements 
from  the  mucous  membrane  seem  to  contain  the  infectious  princi- 
ple in  the  most  concentrated  form,  though  it  has  been  proven  that 
the  blood  contains  the  element  of  the  disease,  as  its  inoculation 
imparts  the  infection  from  the  sick  to  the  well.  The  infection  seems 
to  be  volatile,  as  a  brief  exposure  of  infected  fomites  to  the  air  renders 
them  innocuous.  Experiments  upon  measles  patients  for  the  object 
of  proving  that  the  breath  contains  the  elements  of  infection,  made 
by  causing  affected  persons  to  breathe  through  glass  tubes  coated  on 
the  inner  surface  with  glycerine,  resulted  in  the  discovery,  micro- 
scopically, of  bacteria,  which  develop  to  a  certain  point  in  their 
career,  in  a  proper  medium,  aucl  then  disappear.  They  have  also 
been  found  in  the  blood,  in  the  true  skin,  in  sweat  glands,  and  in  the 
lymph  spaces.  They  occur  in  a  variety  of  shapes:  ovoid,  spherical, 
rod-shaped,  spindle-shaped,  etc.  The  infection  begins  with  the  com- 
mencement of  catarrhal  symptoms,  and  continues  until  some  time 
after  the  rash  has  faded.  A  single  attack  usually  confers  immunity, 
though  two  or  more  attacks  occasionally  occur  in  the  same  person. 
It  is  largely  a  disease  of  children,  because  it  is  so  intensely  conta- 
gious that  children  are  not  liable  to  escape  it,  but  adults  are  fully 
as  susceptible  as  children  if  not  protected  by  a  former  attack,  and 
it  is  much  more  severe  in  its  effects  when  attacking  adults  than  chil- 
dren. Endemic  in  populous  centers,  it  becomes  epidemic  at  intervals. 

Pathology. — Autopsies  of  cases  resulting  fatally  furnish  evi- 
dence that  some  complication  and  not  the  disease  itself,  strictly,  has 
been  the  occasion  of  the  fatal  issue.  The  common  febrile  changes 
in  the  blood,  such  as  loss  of  fibrin,  lack  of  coagulability,  and  dark 
color,  with  hypostatic  congestion  of  the  lungs,  hyperaemia  of  the 
mucous  membranes,  liver,  and  other  internal  organs,  wifh  extrav- 
asation into  their  structures,  are  present.  The  skin  affords  evi- 
dence of  active  alteration,  in  swelling  of  the  corium,  as  well  as  of  the 


142  SPECIFIC  INFECTIOUS  DISEASES. 

rete  Malpighii,  from  active  cell  proliferation,  this  extending  along 
the  hair  and  sweat-gland  ducts  into  the  glands.  The  bacteria 
already  described  as  existing  iu  the  breath  are  found  in  the  liver, 
the  external  layer  of  the  cutis  vera,  in  the  sweat  glands,  in  the  lungs, 
and  other  parts.  In  most  severe  cases  of  measles,  capillary  bron- 
chitis is  a  common  attendant  or  complication,  and  catarrhal  pneu- 
monia is  commonly  associated  with  it.  The  severity  of  measles 
depends  much  upon  epidemic  influences,  a  cerebro-spinal  complica- 
tion sometimes  prevailing,  rendering  an  epidemic  extremely  fatal. 
Gastro-intestinal  hyperaemia  may  sometimes  be  marked,  giving  rise 
to  gastric  and  enteric  symptoms.  Hypersemia  of  the  conjunctiva  is 
a  common  condition,  and  in  adults  who  are  severely  affected  this 
may  involve  the  Meibomian  glands  and  even  the  lymphatics  associ- 
ated with  them,  terminating  in  lymphangitis  and  suppuration,  as 
well  as  suppuration  of  the  Meibomian  glands,  to  be  followed  by 
chronic  irritation  of  these  structures,  with  frequent  recurrence  of 
swelling  and  suppuration  of  the  edges  of  the  eyelid,  as  long-perpet- 
uated sequelae. 

The  eruption  is  papular  in  character,  the  papules  first  appearing 
on  the  face.  They  gradually  extend  to  all  parts  of  the  body, 
appearing  last  upon  the  back  of  the  hands.  The  papules  constitute 
the  red  patches,  and  are  the  result  of  inflammation  of  the  seba- 
ceous follicles,  each  representing  the  center  of  a  reddened  semiluuar 
patch.  In  the  center  of  each  patch,  in  many  places,  will  be  found  a 
central  hair.  The  papules  may  be  felt  better  by  the  finger  than 
seen,  in  many  cases.  If  there  has  been  profuse  sweating,  the  epi- 
dermis may  be  raised  into  small  vesicles,  or  if  the  inflammation  has 
been  very  active,  there  may  be  extravasations  of  blood  into  the  skin. 
Sometimes  there  is  coalescence  of  the  patches  in  places,  especially 
about  the  face,  and  oedematous  spots  result. 

Symptoms. — The  average  period  of  incubation  is  estimated  by 
reputable  authors  as  about  eight  days,  though  frequently  a  much 
longer  time  elapses  after  exposure  before  the  disease  develops. 
Some  authors  give  two  weeks  as  the  average  time.  From  eight  days 
to  two  weeks  may,  then,  be  regarded  as  a  fair  estimate.  During  this 
time,  the  disease  remains  latent,  the  subject  experiencing  no  knowl- 
edge of  its  presence. 

The  first  noticeable  feature  of  an  onset  of  measles  in  a  child  will 
probably  be  announced  by  the  appearance  of  catarrhal  symptoms. 
The  patient  is  observed  to  be  troubled  with  "snuffles,"  cough,  prob- 
ably, watery  eyes,  with  photophobia,  and  he  is  peevish  and  fretful, 
complaining  of  headache  and  chilliness.  A  marked  chill  is  not  com- 
mon, though  for  a  little  time  now  the  thermometer  may  register  a 


MEASLES. 


143 


subnormal  temperature.  The  cough  is  peculiarly  harsh  and  rasping, 
•\vithout  moisture.  The  headache  is  confined  largely  to  the  frontal 
sinuses,  and  is  dull,  aching,  and  constant.  Sometimes  the  onset  is 
more  abrupt,  convulsions  ushering  in  the  initial  symptoms,  or  the 
fever  being  high  from  the  start.  At  all  events,  febrile  symptoms  will 
bocome  established  within  twenty-four  hours,  secretion  being  arrested, 
the  skin  becoming  hot  and  dry,  the  urine  scanty  and  high  colored, 
there  being  loss  of  appetite,  thirst,  and  restlessness. 

The  temperature  is  not  usually  excessively  high  in  measles,  nor  is 
the  pulse  so  rapid  as  in  scarlatina.      The  temperature  ranges  from 

100°  to  104°  F.,  slight  diurnal 


DAY 

OF- 

DISEASE 


/0«T 
10*  ' 
101' 
100' 

39° 
98' 
SI 


1 


S 


4 


3 


9  W 


TEMPERATURE  CUKVE  IN  MEASLES. 


remissions  occurring  with  grad- 
ual rise,  until  the  eruption  has 
reached  its  height,  when  it 
abruptly  falls,  the  temperature 
reaching  normal  within  thirty- 
six  or  forty-eight  hours.  The 
pulse  may  run  from  100  to  120, 
and  in  young  children  it  may 
run  as  high  as  160,  but  is  not 
much  altered  in  character,  except 
as  regards  frequency. 

Before  the  eruption  appears, 
an  examination  of  the  throat  will 
enable  one  to  detect  dark  red 
spots  on  the  soft  palate  and 
fauces,  which  later  become  dif- 
fused over  the  surface,  marking  the  approach  of  the  cutaneous  erup- 
tion. The  cutaneous  eruption  appears  at  the  end  of  the  third  or 
the  beginning  of  the  fourth  day,  exceptionally  as  late  as  the  fifth. 
It  first  appears  as  small  spots  of  raspberry-red  color,  on  the  fore- 
head and  sides  of  the  face,  spreading  to  the  neck,  cheeks,  breast, 
and  down  the  body,  usually  covering  the  entire  surface  —  lastly  invad- 
ing the  back  of  the  hands  —  in  about  four  days  from  its  first  appear- 
ance on  the  forehead.  The  spots  rapidly  coalesce  into  irregular 
crescentic  patches,  with  intervening  spaces  of  unaffected  tissue. 
About  the  face  these  patches  often  become  oedematous. 

During  the  progress  of  the  eruption,  the  fever  becomes  aggra- 
vated, and  the  cough  is  more  deep,  harsh,  and  rasping,  often  being 
almost  continuous.  The  headache  is  now  severe,  the  respirations 
hurried,  and  wheezing  in  many  instances,  and  there  is  marked  dread 
of  light,  the  eyes  being  sensitive  and  suffused.  There  is  itching 


144  SPECIFIC  INFECTIOUS  DISEASES. 

and  burning  of  the  skin,  epistaxis  is  common,  and  there  is  enlarge- 
ment of  the  superficial  lymphatic  glands.  When  the  eruption  is 
fully  developed,  the  finger  drawn  over  the  surface  will  leave  a  white 
line,  which,  however,  rapidly  disappears.  The  eruption  recedes  pro- 
gressively in  the  course  that  it  pursued  while  making  its  appearance, 
beginning  first  with  the  parts  where  it  appeared  first  and  following 
the  line  of  its  development.  The  marked  redness  gradually  disap- 
pears, the  redness  assuming  a  yellowish  tinge  and  gradually  fading 
out,  until  the  last  sign  is  a  slight  staining  of  the  surface. 

The  desquamative  stage  bears  little  resemblance  to  that  of  scar- 
latina. Instead  of  being  scaly  or  branny,  the  cuticular  elements  fall 
off  in  the  form  of  fine  powder,  often  being  unappreciable  to  the 
observer,  and  it  is  unattended  by  fever  or  other  constitutional  dis- 
turbance, the  temperature  being  normal  and  convalescence  established. 

Atypical  Course. — The  regular  course  of  measles  may  be 
interrupted  by  omission  of  some  prominent  stag6|  or  marked  vari- 
ation may  occur,  signally  altering  the  character  of  the  disease. 
Sometimes  the  catarrhal  symptoms  are  absent  and  the  eruption 
appears  without  any  warning.  Such  cases  are  styled  morbilli  sine 
catarrho.  Other  cases  occur  in  which  the  eruption  is  absent,  or  at 
least  very  scanty.  In  these  cases  the  catarrhal  symptoms  are 
marked,  and  there  can  be  no  mistaken  diagnosis,  as  the  disease  will 
be  prevailing  with  regular  symptoms  in  other  patients.  Cases 
occurring  without  the  eruption  are  referred  to  as  morbilli  sine  exan- 
themate.  So-called  black  measles  occurs  in  different  forms,  all  pre- 
senting evidence  of  more  or  less  malignancy,  and  being  due  to  the 
occurrence  of  the  disease  among  bad  hygienic  surroundings.  In  one 
form  there  will  be  about  the  same  initiatory  symptoms,  but  the  tem- 
perature will  be  very  high,  ranging  from  106°  to  107°.  Restlessness 
and  delirium  may  now  be  marked,  the  tongue  will  become  dry,  and 
the  eruption  will  appear  dark  from  the  very  beginning,  important 
changes  in  the  blood  being  so  indicated.  This  may  be  due  partly  to 
epidemic  influences,  such  cases  being  likely  to  occur  frequently  dur- 
ing certain  epidemics,  while  they  may  not  be  seen  at  all  during 
others.  In  this  case  also  the  temperature  runs  a  remarkably  high 
course.  In  still  another  class  of  cases  the  eruption  appears  in 
petechial  black  spots  scattered  over  the  surface,  due  to  a  hemor- 
rhagic  condition  of  the  patient.  In  connection  with  thjs  symptom, 
hemorrhages  from  the  mouth,  nose,  stomach,  intestinal  tract,  and 
kidneys,  is  liable  to  occur.  These  are  considered  very  grave  forms 
of  the  disease. 

Complications  and  Sequelae. — Congestion  of  the  branchial 
mucous  membrane  is  one  of  the  conditions  of  this  disease,  but  it 


MEASLES.  145 

may  become  so  aggravated  as  to  constitute  a  complication.  The 
sonorous  rales  beard  ordinarily  over  the  chest  are  common  to  the 
usual  case  of  mea.sles;  but  when  capillary  bronchitis  arises,  the  con- 
dition may  be  considered  a  complication,  as  it  is  by  far  the  most 
serious  element  of  the  disease.  There  are  now  small  crackling  and 
subcrepitant  sounds  over  the  affected  area,  with  absence  of  the  nor- 
mal respiratory  murmur.  When  lobular  pneumonia  is  present,  the 
symptoms  are  much  the  same  as  these,  except  that  there  is  dullness 
on  percussion  over  the  affected  portion.  There  is  now  marked 
increase  in  the  rise  of  temperature,  the  pulse  is  increased  in  fre- 
quency, the  respiration  is  hurried  and  difficult,  and  the  countenance 
is  cyanotic  in  appearance. 

The  conjunctival  congestion  may  also  constitute  a  complication, 
this  sometimes  becoming  prominent,  purulepcy,  with  a  high  grade  of 
inflammatory  action  attending.  Ulceration  of  the  cornea  sometimes 
occurs,  followed  by  rapid  destruction  of  vision. 

Stomatitis  sometimes  occurs  as  a  complication,  the  mouth  being 
swollen,  hot,  and  dry,  and  often  extensively  ulcerated,  though  this  is 
most  apt  to  be  the  case  where  the  patient  has  been  mercurialized. 
Here  the  fauces  and  pharynx  may  be  involved,  and  the  trouble  may 
expose  the  glottis,  causing  oedema  and  suffocation.  Sometimes  it,  as 
well  as  the  other  complications,  may  be  peculiar  to  some  certain  epi- 
demic, being  present  in  almost  every  case,  to  greater  or  less  extent. 

Extension  of  the  inflammation  of  the  pharynx  into  the  eusta- 
chian  tubes,  and  from  there  into  the  middle  ear  may  occur,  giving  rise 
to  suppuration  and  perforation  of  the  tympanum,  and  even  suppu- 
ration in  the  mastoid  cells,  to  be  followed  by  a  long  train  of  unpleas- 
ant and  serious  symptoms. 

Cerebro-spinal  meningitis  occasionally  occurs  as  a  complication  of 
an  epidemic  of  measles,  the  disease  presenting  many  of  the  symp- 
toms of  cerebro- spinal  fever.  When  this  occurs,  the  disease  becomes 
protracted  and  stubborn.  The  rash  may  fade  out,  the  bronchial 
symptoms  persist,  and  continue  until  the  patient  is  worn  out  and 
exhausted.  Or,  convulsions  may  set  in  and  terminate  the  case 
speedily. 

Diagnosis. — With  the  dry,  harsh  cough  and  other  catarrhal 
symptoms  of  measles  combined  with  the  eruption,  the  disease  can 
hardly  be  mistaken  for  any  other  of  the  exanthemata.  In  no  other 
affection  is  the  persistent  cough  so  noticeable.  If,  however,  it 
should  happen  that  a  severe  pulmonary  complication  should  attend 
rubella  or  scarlatina,  the  watery  eyes  and  nasal  symptoms  would 
hardly  be  counterfeited.  In  children,  the  eruption  of  typhus  fever 
might  resemble  that  of  measles,  but  in  typhus  the  rash  does  not 


146  SPECIFIC  INFECTIOUS  DISEASES. 

appear  on  the  face,  while  here  is  the  first  place  it  appears  in  mea- 
sles. Nor  is  the  eruption  accompanied  by  catarrhal  symptoms  in 
typhus,  while  the  delirium  of  that  disease  is  absent  in  measles, 
unless  it  be  the  typhoid  form.  Then,  the  history  of  the  case  will 
go  far  toward  settling  any  matter  of  dispute  of  this  nature.  The 
absence  of  severe  cough  and  other  catarrhal  symptoms  will  be  a 
diagnostic  point  where  there  might  be  a  mistaken  identity  between 
this  disease  and  rubella.  Early  enlargement  of  the  posterior  cer- 
vical gjands  in  rubella  would  assist  in  the  discrimination,  as  well  as 
the  marked  congestion  of  the  fauces,  which  is  not  very  prominent  in 
measles,  even  though  the  exanthem  is  early  spread  over  the  soft 
palate. 

It  is  hardly  possible  to  confound  measles  and  scarlatina,  as  the 
catarrhal  symptoms  are  so  much  more  marked  in  the  former,  while 
the  inflammation  of  the  fauces  in  the  latter  disease  is  of  a  pro- 
nounced character. 

Prognosis. — The  prognosis  of  this  disease  will  vary  much, 
according  to  the  circumstances  attending.  When  the  patient  is 
placed  under  favorable  circumstances  for  good  nursing  and  this  is 
supplied,  hardly  any  uncomplicated  case  ought  to  terminate  fatally. 
A  warm  room,  where  the  air  can  be  kept  at  an  even  aud  somewhat 
elevated  temperature,  is  essential  to  a  favorable  recovery  from  the 
bronchial  irritation.  The  poor,  then,  who  are  badly  housed,  and 
whose  houses  are  but  indifferently  warmed,  and  those  who  are  una- 
voidably exposed  to  cold  air,  such  as  soldiers,  are  not  favorable  sub- 
jects during  winter  weather,  as  serious  pulmonary  complications  are 
almost  certain  to  arise,  which  render  the  prognosis  unfavorable. 
The  age  of  the  patient  also  exerts  an  important  influence  upon  the 
question  of  prognosis,  children  recovering  with  much  less  liability 
to  serious  complication  than  adults.  Black  measles,  either  the  hem- 
orrhagic,  ulcerative,  or  typhoid  form,  presents  us  with  grave  diffi- 
culties, and  the  prognosis  should  be  extremely  guarded.  Measles 
occurring  during  pregnancy  is  liable  to  prove  fatal  to  the  foetus, 
absorption  being  the  probable  result,  though  the  mother  may  not 
suffer  severe  effects.  Marked  disturbance  of  the  menstrual  function 
is  liable  to  follow  a  severe  attack  of  measles  in  the  adult  female.  It 
has  been  said  that  when  a  pregnant  woman  passes  through  an  attack 
of  measles  without  aborting,  the  child  is  as  well  protected  against 
future  attacks  as  though  affected  after  birth.  Capillary  bronchitis, 
pneumonia,  croupous  laryngitis,  diphtheria,  and  cerebro-spitial  men- 
ingitis, are  all  serious  complications,  and  the  presence  of  either  of 
them  might  be  considered  as  reason  for  a  guarded  prognosis. 

Treatment. — The  preventive  treatment  consists  of  strict  quar- 


MEASLES.  147 

antine  against  the  disease,  confining  those  who  are  affected  to  sepa- 
rate quarters,  and  isolating  the  nurses  and  attendants.  Excretions, 
and  all  clothing  worn  by  the  patient  and  nurses,  should  be  thoroughly 
disinfected,  as  in  typhoid  fever,  and  the  quarantine  should  continue 
until  the  period  of  desquamatiou  has  ended.  It  is  hardly  desirable 
to  quarantine  all  epidemics  of  measles,  as  children  suffer  less  from 
the  disease  than  adults,  except  during  infantile  age,  and,  as  the  con- 
tagion almost  always  exhausts  every  community  of  unprotected  sub- 
jects, an  escape  during  childhood  only  destines  the  adult  to  a  more 
severe  attack  during  maturity.  However,  as  some  epidemics  are 
attended  by  malignant  symptoms  in  almost  every  case,  avoidance  of 
the  disease  is  always  commendable  at  such  times. 

The  medicinal  treatment  of  uncomplicated  measles  is  simple, 
though  the  practitioner  should  be  on  the  alert  for  complications, 
that  their  severity  may  be  modified  early.  To  control  the  conges- 
tion of  the  mucous  membrane  to  some  extent,  control  the  cough  and 
encourage  early  departure  of  the  cough  and  coryza,  the  use  of  small 
doses  of  jdborandi  and  asdepias,  in  combination,  serves  an  excellent 
purpose.  Add  a  drachm  of  each  to  half  a  glass  of  water,  and  give  a  tea- 
spoonful  every  hour.  This  will  modify  the  cough,  assuage  the  fever, 
quiet  restlessness,  and  impart  a  sensation  of  coolness  and  comfort 
to  the  skin,  as  well  as  lessen  the  severity  of  all  the  congestive 
symptoms.  Alkaline  baths  to  the  skin  are  grateful,  though  they 
should  be  warm.  The  room  should  be  darkened  so  as  to  prevent 
the  bright  light  from  irritating  the  eyes,  and  when  these  organs  are 
much  irritated,  cold  compresses  are  of  service  to  assist  in  prevent- 
ing later  complications  and  sequelae  of  this  character.  The  temper- 
ature of  the  room  should  be  warm  and  equable  throughout  the 
course  of  the  disease,  as  cool  air  is  aggravating  to  the  cough. 

Sometimes  the  patient  will  object  very  much  to  jaborandi,  as 
well  as  asclepias,  and  something  less  objectionable  may  be  required. 
Aconite  and  rhus  tox.  afford  satisfaction  in  the  majority  of  cases, 
and  this  combination  is  especially  to  be  recommended  where  there 
is  marked  restlessness,  with  a  tendency  to  delirium  at  night.  Add 
five  drops  or  less  (according  to  the  age  of  the  child)  of  aconite,  and 
ten  or  fifteen  of  rhus  (or  less  in  very  young  children)  to  half  a  glass 
of  water,  and  give  a  teaspoonful  every  hour.  This  is  essentially  the 
prescription  where  there  is  gastro-intestinal  irritation,  with  nausea, 
vomiting,  or  diarrhoea. 

The  cough  sometimes  proves  a  stubborn  symptom,  and  demands 
especial  attention.  One  of  the  most  successful  remedies  for  the 
cough  of  measles  is  drosera,  which  may  be  administered  by  adding 
ten  or  twenty  drops  to  four  ounces  of  water,  and  giving  a  teaspoon- 


148  SPECIFIC  INFECTIOUS  DISEASES. 

ful  every  hour.  Sometimes  this  will  fail  to  afford  satisfaction,  and 
we  will  need  to  resort  to  sticta,  sanguinaria,  or  ipecac.  Echinacea 
will  sometimes  cut  short  a  cough  of  this  character  after  more 
approved  drugs  have  failed.  When  the  cough  arises  from  catarrh  of 
the  smaller  tubes — capillary  bronchitis,  evidenced  by  stuffy,  sull'u- 
cative  cough,  purple,  cyanotic  countenance,  and  dyspnoea — tartar 
emetic,  2x  or  3x  (3x  for  children),  will  be  the  proper  remedy.  Two 
or  three  grains  may  be  administered  at  a  dose,  repeated  every  two 
hours  until  the  special  symptoms  demanding  the  remedy  disappear. 
Where  chronic  catarrhal  symptoms  persist,  three  grains  of  calcarea 
carb.,  every  three  or  four  hours,  may  be  administered  to  complete 
the  cure. 

Malignant  measles  demands  remedies  to  correct  depraved  states 
of  the  blood,  in  the  majority  of  instances.  Specific  indications  will 
often  point  out  the  proper  agent  to  correct  the  basic  lesion  and  place 
the  system  in  such  a  condition  that  the  ordinary  remedies  are  suc- 
cessful in  these  cases.  Where  there  is  excessive  acidity  of  the  stom- 
ach, as  manifested  by  the  broad,  flabby  tongue,  with  pasty  white 
coating,  sulphite  of  sodium  will  be  the  proper  corrective.  It  may 
be  given  in  from  one-  to  three-grain  doses  every  two  or  three  hours, 
until  the  marked  indications  are  removed.  The  brown  coating  on 
the  tongue  will  suggest  sulphurous  acid,  and  this  should  be  given  a 
leading  place  in  the  treatment,  until  the  marked  indication  for  the 
remedy  has  vanished.  Ten  or  twenty  drops  of  a  reliable  prepara- 
tion, well  diluted  with  water,  should  be  administered  at  a  dose,  every 
three  or  four  hours.  During  the  course  of  the  disease,  the  clean, 
slick,  dark-red  tongue  (beefsteak  tongue)  may  be  developed,  calling 
for  appropriate  doses  of  hydrochloric  acid.  In  many  of  these  con- 
ditions the  patient  will  be  very  sick,  some  peculiar  unpleasant  fea- 
ture or  symptom  being  more  than  ordinarily  prominent.  Typhoid 
symptoms  are  almost  certain  to  be  present,  a  strong  tendency  to 
delirium  or  coma  attending,  and  the  temperature  running  high  in 
comparison  with  that  of  ordinary  cases.  Where  there  is  a  ten- 
dency to  coma,  with  cold  extremities,  the  sedative  in  these  cases 
may  be  replaced  with  minute  doses  of  belladonna,  two  drops  of  the 
specific  medicine  to  four  ounces  of  water,  combined  with  minute 
doses  of  aconie;  dose,  a  teaspoonful  every  hour.  In  the  majority 
of  these  cases,  however,  echinacea  will  answer  a  better  purpose,  its 
corrective  influence  on  the  depraved  condition  of  the  blood  being 
better,  while  it  is  as  positive  a  remedy  to  improve  the  capillary  cir- 
culation as  belladonna.  In  the  petechial  form,  as  well  as  that 
attended  by  ulceration  »  f  the  mouth,  echinacea  will  be  found  an 
excellent  resort  to  correct  the  depravity  of  the  blood  and  prevent 


MEASLES.  149 

phagedenic  processes.  Oar  older  therapeutists  would  have  pro- 
posed baptisia  here,  but  this  was  before  the  profession  was 
acquainted  with  the  remarkable  properties  of  echinacea. 

In  epidemics  where  cerebro-spinal  disturbances  are  marked,  we 
will  find  echinacea  our  best  resort,  it  being  the  best  remedy  we  pos- 
sess for  cerebro-spiual  fever,  or  for  its  complications.  A  drop  for 
e;ich  year  of  age  up  to  fifteen  will  be  as  satisfactory  a  plan  of  dos- 
age as  any  other,  for  this  remedy.  It  may  be  repeated  every  two 
hours,  in  urgent  cases. 

A  markedly  high  temperature  may  sometimes  attend,  and  some- 
times we  find  this  present  where  the  extremities  are  cold  and  the 
circulation  in  the  superficial  capillaries  feeble.  Where  the  remedies 
already  suggested  fail  to  produce  a  sedative  effect,  I  would  suggest 
the  use  of  salicylate  of  ammonium,  in  appropriate  doses. 

Convulsions  occurring  during  the  onset  of  this  disease  will  not 
require  special  treatment,  aconite  and  rhus,  as  directed  for  ordinary 
sedative  purposes,  being  the  proper  remedies  here.  If  called  dur- 
ing the  convulsive  action,  the  physician  may  direct  the  child  to  be 
put  in  a  warm  bath,  or  wrapped  in  a  flannel  blanket  wrung  out  of 
warm  water.  As  soon  as  the  action  of  the  sedative  is  established, 
the  signs  of  convulsions  disappear. 

Warm  alkaline  baths  are  sometimes  of  service  where  the  erup- 
tion is  attended  by  severe  burning  and  itching,  and  in  black  measles 
where  there  is  feeble  capillary  circulation,  or  where  there  has  been 
a  retrocession  of  the  rash,  as  well  as  where  the  rash  is  tardy  in 
making  its  appearance  and  the  patient  seems  to  be  suffering  on  that 
account,  a  sponge  bath  of  aqua  ammonia  diluted  in  water  (an  ounce 
to  a  quart  of  water)  will  often  assist. 

Where  pulmonary  symptoms  are  pronounced,  a  pack  of  cloths 
wrung  out  of  tepid  water,  applied  to  the  chest,  will  be  found  an  excel- 
lent auxiliary  to  the  properly  selected  remedy,  frequently  affording 
speedy  relief  to  urgent  symptoms,  such  as  dyspnoea,  cough,  etc. 

The  diet  during  measles  should  be  mild  and  unstimulating  in 
character,  but  nutritious.  Plain  milk,  lime  water  being  added  for 
young  children,  or  what  is  better,  malted  milk,  will  furnish  all  the 
nourishment  needed  during  the  active  period  of  the  disease.  Later, 
during  the  desquamative  stage,  solid  food  may  be  taken,  moderately 
at  first.  Cold  water  may  be  allowed  freely  during  all  stages  of  this 
disease,  as  well  as  during  all  fevers,  provided  there  is  no  gastric 
irritation  present,  to  contraindicate  its  frequent  use.  Ice  water, 
however,  is  too  cold. 

During  the  stage  of  desquamatiou  and  immediately  afterward, 
the  skin  is  poorly  protected  against  draughts  of  air  and  sudden 


150  SPECIFIC  INFECTIOUS  DISEASES. 

changes,  and  should  be  well  clothed,  as  there  is  almost  as  ranch 
danger  to  the  pulmonary  organs  as  to  the  kidneys  during  the 
late  stage  of  scarlatina.  Inunction  of  the  skin  with  lard  or  olive 
oil  is  a  commendable  measure  where  there  is  the  least  possibility 
that  the  patient  may  become  chilled.  During  winter,  spring,  and 
autumn,  in  the  Eastern  States,  this  measure  is  an  important  one. 
Flannels  should  be  worn  invariably,  for  several  weeks  after 
convalescence, 

X.  RUBELLA. 

Synonyms. — Rotheln;    German   Measles:    Epidemic   Roseola. 

Definition. — A  specific,  mildly  contagious,  eruptive  disease, 
resembling  measles  many  times  in  its  eruption  at  others  scarlatina, 
and  resembling  scarlatina  in  the  accompaniment  of  sore  throat,  but 
lacking  the  cough  and  other  catarrhal  symptoms  that  characterize 
measles,  and  the  high  temperature  and  sequel»  that  usually  attend 
scarlatina. 

Etiology. — Rubella  occurs  epidemically,  and  is  feebly  conta- 
gious. The  contagious  character  of  the  disease,  however,  is  not  so 
marked  as  that  of  scarlatina  and  measles,  several  instances  coming 
under  my  observation  where  one  in  a  family  of  children  has  been 
affected  while  the  others  escaped,  and  there  were  many  other  iso- 
lated cases  in  the  same  neighborhood;  though  usually  the  majority 
of  children  in  families  are  affected,  when  it  is  once  introduced. 
It  seems  that  the  intensity  of  the  contagious  principle  differs  dur- 
ing different  epidemics,  the  disease  sometimes  manifesting  marked 
contagiousness,  and  again  seeming  to  be  but  slightly  contagious,  if 
at  all.  This  is  probably  the  reason  why  there  is  such  a  difference 
of  opinion  among  medical  authors  on  the  subject,  some  claiming 
that  it  is  eminently  contagious,  while  others  of  fully  as  much  relia- 
bility aver  that  it  is  not  contagious  at  all.  In  some  epidemics,  chil- 
dren are  the  only  subjects  affected,  while  in  others,  adults  are  com- 
monly attacked.  In  such  cases,  adults  suffer  fully  as  much,  if  not 
more,  than  children.  It  is  asserted  that  a  single  attack  affords  pro- 
tection from  subsequent  ones  of  the  same  disease,  though  it  is  cer- 
tain that  it  affords  no  immunity  from  measles  or  scarlatina. 

Pathology. — The  most  marked  pathological  changes  occur  in 
the  skin,  throat,  and  cervical  glands,  though  these  are  not  of  radical 
character.  The  skin-changes  consist  of  irregular  hypersemic  blotches, 
which  vary  in  size  from  a  pin's  head  to  a  fourth  of  an  inch  in  diam- 
eter. They  are  slightly  elevated,  but  disappear  under  pressure,  and 
do  not  impart  the  hardened  feel  to  the  touch  that  is  observed  in  the 
early  stage  of  measles,  indicating  less  plastic  exudation,  and  less 


RUBELLA.  151 

inflammatory  action.  The  eruption  appears  upon  all  parts  of  the 
body,  and  the  patches  are  round — not  crescentric,  like  those  of  mea- 
sles. There  is  no  exudation  of  serous  or  lymphoid  material  into  the 
rete  Malpighii  as  in  scarlatina,  nor  inflammation  of  the  sebaceous 
follicles,  as  in  measles.  The  throat  is  congested,  sometimes  markedly 
so,  and  the  cervical  lymphatics,  especially  the  posterior  cervical, 
are  swollen  and  tender,  even  early  in  the  course  of  the  disease. 
Slight  powdery  desquamation  from  the  skin  occurs,  but  seldom  in 
the  form  of  flakes,  as  occurs  in  scarlatina.  The  important  conges- 
tion of  internal  organs  that  marks  the  more  severe  forms  of  erup- 
tive fevers,  is  not  present  to  any  considerable  extent  in  this. 

Symptoms. — The  stage  of  incubation  is  said  to   be   about   two 
weeks  in  length. 

The  stage  of  invasion  is  hardly  noticeable  in  many  cases,  though 
there  may  be  a  distinct  chill,  and  even  convulsions,  during  the 
attack.  The  eruption  occurs  within  twenty-four  hours  after  the  inva- 
sion, though  many  cases  manifest  no  unpleasant  symptoms  until  the 
appearance  of  the  eruption,  the  child  being  at  play  when  it  is  first 
noticed.  It  appears  first  on  the  face,  and  spreads  over  the  entire 
body  within  two  or  three  days,  disappearing  within  twelve  or  twenty- 
four  hours  after  its  appearance,  a  progressive  subsidence  following 
the  march  of  its  appearance.  The  rash  varies  in  color  from  the 
scarlet  appearance  of  that  of  scarlatina  to  the  raspberry  color  of 
measles.  Often  it  is  but  faintly  marked,  though  the  more  pro- 
nounced the  rash  the  more  severe  the  other  symptoms.  The  rash 
is  often  distinctly  separated  into  little  spots  or  patches,  though 
again  it  may  be  evenly  spread,  as  in  scarlet  rash.  Desquamation 
occurs  as  a  powdery  exfoliation,  the  superficial  parts  of  the  epider- 
mis only  being  involved,  serious  disturbance  of  the  cuticle  of  the 
palms  and  soles  not  being  noticeable,  as  in  scarlatina.  The  pulse  is 
increased  in  frequency,  being,  in  some  cases,  small  and  wiry.  The 
temperature  is  slightly  elevated,  one  or  two  degrees  being  the  average, 
though  in  severe  cas?s  it  may  reach  103°  F. 

The  throat  symptoms  are  sometimes  apparently  quite  severe,  the 
tumefaction  and  difficulty  of  swallowing  being  marked  and  trouble- 
some, though  the  irritation  is  superficial,  as  manifested  by  absence 
of  sloughing  or  destructive  action  later.  Sometimes  the  follicles  of 
the  tonsils  are  involved,  and  white  patches  of  exudative  material 
appear  about  their  orifices.  The  redness,  however,  does  not  spread 
over  the  palate,  as  in  scarlatina.  The  muscles  of  the  neck  are  often 
stiff  and  painful,  and  the  muscles  of  the  body  generally  are  sore,  the 
patient  complaining  of  a  bruised  feeling.  Muscular  rheumatism  may 
attend  severe  cases.  The  cervical  lymphatics  will  be  found  swollen 


152  SPECIFIC  INFEC1IOUS  DISEASES. 

and  tender  early  in  the  course  of  many  cases,  especially  the  occip- 
ital lymphatics.  Most  cases  are  so  mild  that  the  patient  considers 
it  a  hardship  to  remain  in  bed,  and,  if  allowed,  he  will  be  up  and 
around  before  the  appearance  of  the  eruption. 

The  tongue  is  coated  with  a  thin  white  coating,  early,  through 
which  dark  red  points  appear,  and  later  the  organ  may  appear  slick 
and  dark  red  in  color.  The  organ  is  usually  pointed  and  reddened 
at  the  tip,  though  there  is  rarely  nausea  or  vomiting. 

Complications  and  *equclce  are  almost  unknown  in  this  disease,  and 
although  these  are  mentioned  by  authors  as  occasionally  occurring 
(anasarca,  for  instance),  it  seems  that  such  can  only  be  the  case 
where  a  very  bad  plan  of  treatment  has  been  pursued. 

Diagnosis. — Probably  there  is  no  other  disease  known  in  which 
physicians  make  so  many  blunders  in  diagnosis  as  in  this.  The 
blunder,  however,  is  usually  on  the  safe  side — for  their  credit — as 
they  commonly  diagnose  it  as  scarlatina.  The  great  number  of 
cases  of  scarlatina  which  occur  around  us  with  no  mortality  would 
be  surprising,  were  it  not  for  the  fact  that  the  physicians  who  man- 
age them  are  the  most  arrant  blunderers  in  therapeutics  possible, 
in  most  instances,  and  really  sometimes  find  it  difficult  to  pull  a  sim- 
ple case  of  rubella  through  successfully.  About  as  positive  a  diag- 
nostic point  as  can  be  scored  then  is  that  if  no  mortality  or  sequelae 
attend  we  are  having  an  epidemic  of  rubella.  Mark  the  low  temper- 
ature, the  absence  of  violent  gastro-intestinal  symptoms,  of  delirium, 
and  destructive  action  in  the  throat,  which  attends  scarlatina.  Mark 
also  the  absence  of  pronounced  catarrhal  symptoms,  the  absence  of 
the  rough,  deep  cough,  which  announces  measles  to  the  whole  house- 
hold. Mark,  also,  the  brief  stay  of  the  rash,  and  the  small  amount 
of  pyrexia  during  its  presence,  and  you  will  find  enough  distinctive 
features  to  determine  a  case  of  rubella. 

Prognosis. — Without  the  most  absurd  and  irrational  treatment, 
and  the  worst  nursing  imaginable,  and  without  some  unexpected  and 
unwarrantable  complication,  the  prognosis  is  always  favorable. 

Treatment. — A  combination  of  aconite,  rhus  tox.,  and  plnjtolacca, 
from  one  to  five  drops  of  aconite,  fifteen  to  twenty  of  rhus,  and  ten 
to  thirty  of  phytolacca,  in  four  ounces  of  water,  dose,  a  teaspoon ful 
every  hour,  will  represent  the  proper  routine  prescription,  this  cov- 
ering the  usual  indications.  There  may  be  cases  in  which  muscular 
pain  will  be  prominent,  demanding  the  judicious  use  of  a"cfanilide, 
cimicifvga,  or  rhamnus  californica.  Itching  and  burning  of  the  skin 
may  suggest  the  local  use  of  the  resorcin  lotion  recomm  ndcd  for  a 
similar  purpose  under  the  treatment  of  chicken-pox.  Finally,  fatty 
inunction,  during  desquarnation,  is  to  be  commended. 


MUMPS.  153 

XI.  MUMPS. 

Synonyms. — Epidemic  Parotitis;  Specific  Parotitis. 

Definition. — Mumps  is  an  acute,  contagious  inflammation  of 
one  or  both  parotid  glands,  attended  with  fever,  and  usually  result- 
ing in  resolution,  with  a  tendency  to  metastasis  to  the  testes  in  the 
male,  and  to  the  ovaries  or  mammary  glands  in  the  female. 

Non-specific  or  metastatic  parotitis  may  occur  as  a  secondary 
symptom  in  certain  infective  diseases,  such  as  typhoid  fever,  Dyae- 
mia,  diphtheria,  measles,  etc.,  and  usually  terminates  in  abscess. 
In  the  idiopathic  variety,  this,  as  a  rule,  does  not  occur. 

Stephen  Paget  has  collected  a  large  number  of  cases  in  which 
injury  or  disease  of  the  abdominal  or  pelvic  organs,  unattended  by 
septic  processes,  was  followed  by  an  idiopathic,  non-specific  parotitis. 

Etiology. — Mumps,  like  the  eruptive  fevers,  is  propagated  by 
contagium,  and,  like  them,  one  visitation  usually  confers  immunity 
from  subsequent  attacks.  However,  a  person  having  "single  mumps" 
is  liable  to  a  later  invasion — of  the  other  gland. 

Pasteur  claimed  to  have  discovered  the  "bacillus  parotidis,"  but 
attempts  at  the  inoculation  of  animals  with  it  have  failed,  and  the 
nature  of  the  virus  is  therefore  still  an  open  question. 

Mumps  rarely  occurs  sporadically.  On  the  coasts  of  France, 
Holland,  England,  and  some  localities  in  this  country,  it  is  said  to 
be  epidemic.  Isolated  cases  are  occasionally  met  with,  but  it  usu- 
ally occurs  iu  the  epidemic  form.  Mumps  is  a  disease  of  childhood, 
the  period  when  the  system  is  most  liable  to  its  invasion  being 
between  the  second  year  and  puberty.  Persons  who  have  escaped 
parotitis  iu  childhood  areliot  necessarily  exempt  from  its  influence; 
in  fact,  during  some  epidemics,  adults  are  chiefly  affected.  Females 
are  not  so  liable  to  contract  the  disease  as  males.  The  immunity  of 
infants  is  attributed  to  the  slight  development  of  the  parotids,  and 
the  narrowness  of  Steno's  duct.  The  humidity  of  the  atmosphere 
undoubtedly  assists  in  the  propagation  of  this  disease,  the  autumn 
and  spring  months  being  the  period  when  it  is  most  frequently  met. 

Pathology. — The  catarrhal  inflammation  commences  primarily 
in  the  ducts,  and  spreads  rapidly  to  the  glandular  structure.  There 
is  at  first  an  intense  hypersemia,  resulting  in  serous  exudation  and 
tumefaction.  The  acini  are  oedematous,  anil  there  is  inflammatory, 
serous,  and  cellular  infiltration  of  inter-alveolar  fibrous  structure, 
the  surrounding  connective  tissue  and  adjacent  parts  being  more  or 
less  involved.  The  inflammation  terminates  by  resolution,  fibrous 
induration,  or  suppuration,  usually  the  first.  Occasionally,  paroti- 
tis results  in  atrophy  of  the  gland. 


154  SPECIFIC  INFECTIOUS  DISEASES. 

Symptoms. — The  period  of  incubation  lasts  from  one  to  three 
weeks,  during  which  there  is  little  premonitory  disturbance,  though 
the  swelling  of  the  parotids  is  often  preceded  by  proclromata, 
the  patient  complaining  of  anorexia,  nausea,  pains  in  the  head 
and  back,  and  constipation.  There  is  a  chili  (or  chilly  sensations), 
followed  by  fever,  quick  pulse,  scanty  urine,  and  a  dry  skin.  The 
patient  complains  of  stiffness  and  tension  in  the  parotids,  and  tume- 
faction, usually  beginning  on  the  left  side.  The  usual  phenomena 
of  inflammation — heat,  pain,  tenderness,  and  swelling — are  present 
The  pain,  while  unpleasant,  cannot  be  termed  severe.  It  is  increased 
by  swallowing,  speaking,  or  pressure.  The  swelling  extends  in  all 
directions,  and  we  have  a  general  cetlema  of  the  affected  side.  The 
lower  jaw  is  greatly  restricted  in  movement,  and  mastication  and 
enunciation  are  difficult,  and,  at  times,  impossible.  Salivation  is  an 
occasional  symptom.  When  stomatitis  and  ptyalism  develop,  there 
is  considerable  fetor.  Occasionally,  the  submaxillary  and  sublin- 
gual  glands  participate  in  the  inflammation,  and  cases  have  been 
reported  where  the  parotids  were  unaffected,  the  swelling  being 
confined  to  the  smaller  salivary  glands.  The  lymphatic  glands  in 
the  immediate  vicinity  are  usually  swollen. 

In  general,  the  fever  is  not  very  high ;  in  fact,  some  cases  run  an 
apyrexial  course,  the  main  discomfort  arising  from  the  tension  over 
the  parotids,  and  the  immobility  of  the  lower  jaw. 

In  from  three  to  four  days  the  disease  has  fully  developed.  About 
the  seventh  or  eighth  day  resolution  and  subsidence  of  the  swelling 
begin,  or,  as  is  often  the  case,  the  other  gland  becomes  involved. 
While  the  above  is  the  usual  course,  some  cases  present  serious  fea- 
tures, there  being  hyperpyrexia,  intense  pain,  delirium,  and  great 
vital  impairment. 

Complications  and  Sequelae. — Where  there  has  been  high 
fever  and  marked  nervous  symptoms,  delirium  and  even  maniacal 
attacks  are  noted,  or,  in  severe  cases,  meningitis,  hemiplegia,  and 
coma.  Cerebral  congestion  may  result  from  pressure  on  the  jugular 
vein.  Visual  affections  are  more  infrequent,  amblyopia  being  the 
most  serious.  Acute  albuminuria,  gastro-intestinal  disturbances, 
and  arthritis,  have  been  noted.  Impairment  of  hearing,  persisting, 
in  some  cases,  is  an  occasional  unpleasant  sequela. 

The  most  frequent  complication,  however,  is  orchitis.  The  testic- 
ular  inflammation  develops  oftenest  after  the  subsidence  of  the 
swelling  in  the  parotid,  and  is  largely  dependent  upon  the  character 
of  the  epidemic — though  too  early  exercise  on  the  feet  may  be  pro- 
vocative of  it  under  other  circumstances,  though  usually  the  severity 
of  the  original  disease  has  little  to  do  with  this  condition.  Bilateral 


MUMPS.  155 

orchitis  is  rare,  although  at  times  the  second  testicle  is  in  turn 
attacked.  It  is  seldom  noticed  before  puberty.  In  an  epidemic 
where  495  soldiers  were  attacked  with  mumps,  Granier  found  115 
cases  of  orchitis.  The  inflammation  does  not  run  any  regular 
course,  although  it  seldom  extends  over  a  week. 

In  the  female,  ovaritis  occasionally  develops,  and,  infrequently, 
mastitis  or  vulvo-vaginitis. 

Suppuration  of  the  parotid  seldom  occurs.  Where  pus  forms, 
there  is  marked  constitutional  disturbance,  and  the  pain  is  severe, 
as  the  glaud  is  provided  with  a  strong  capsule  and  the  surrounding 
fascia  is  deep  and  firm.  As  a  rule,  the  pus  opens  into  the  auditory 
meatus,  but  it  may  pass  along  the  sheath  of  the  carotid  to  the  skull, 
burrow  its  way  behind  the  pharynx  into  the  maxillary  joint,  or  down- 
ward into  the  thorax.  It  is,  therefore,  a  serious  complication. 

Treatment. — Mumps  is  a  self-limiting  disease,  and,  in  the  major- 
ity of  cases,  there  is  not  much  call  for  medicine.  Externally,  a 
layer  of  cotton  wadding  covered  with  oil  silk  is  sufficient,  although 
some  prefer  inunctions  of  oil  or  a  hot  or  cold  compress.  When  the 
pain  is  severe,  a  lead  and  opium  lotion  gives  considerable  relief. 
Phytdacca  is  extolled  by  some.  For  the  fever,  aconite  is  indicated: 
$  Specific  aconite  gtt.  v,  specific  phytolacca  jss,  aqua  q.  s.  f  iv.  M.  S., 
3!  every  hour  or  two.  At  the  beginning,  there  is  frequently  a  defi- 
ciency of  saliva,  and  specific  jaborandi  (-511— jiii)  can  be  added. 

Plyalism  is  sometimes  present  during  the  later  stages,  and  calls 
for  belladonna,  or  the  fractional  dose  of  jaborandi  or  iris. 

-  It  is  seldom  that  there  will  be  a  call  for  any  sedative  except 
aconite,  but  occasionally  there  will  be  an  irritation  of  the  nervous 
system  and  determination  of  blood  to  the  brain,  calling  for  the  exhibi- 
tion of  gelsemium  (jss— fiv),  or  the  sharp  stroke  of  the  pulse  and 
nervous  erethism,  with  or  without  the  tongue  symptoms,  which 
would  indicate  rhus  tox.  (gtt.  x  to  xx— fiv). 

Abscess  is  a  rare  complication  and  must  be  met?  promptly  by  sur- 
gical treatment,  in  order  to  prevent  the  danger  consequent  on  the 
burrowing  of  pus.  Most  cases  are  likely  to  break  in  the  ear  if  not 
interfered  with,  but  the  lance  should  nevertheless  be  used  early. 
Sometimes  it  is  necessary  to  make  a  careful  dissection,  where  tlie 
pus  is  deep.  Where  we  suspect  a  possible  breaking  down  of  the 
glandular  structure,  calcium  sulphide  is  to  be  given  in  small  doses  with 
a  reasonable  expectation  of  its  aborting  the  abscess. 

Orchitis  is  treated  by  rest  and  support  of  the  testes.  Strapping 
is  not  often  called  for.  The  following  lotion  is  about  as  good  as 
anything  to  apply  locally :  R  Plumbi  acet.  31,  tinct.  opii  ?i,  tinct 
aconite  fss,  aqua  q.  s.  fvi.  M.  S.,  Lotion. 


156  SPECIFIC  INFECTIOUS  DISEASES. 

In  other  cases,  a  lotion  consisting  of  equal  parts  of  echinacea, 
phytolacca,  and  belladonn  i  (green  plant  tincture  or  specific  medi- 
cine ),  will  serve  a  better  purpose.  This  may  be  kept  applied  con- 
stantly, with  moistened  cloths.  Inter.  lally,  we  administer  phylo- 
licca  or  pulsa'illa,  with  our  sedative. 


XII.  WHOOPING 

Synonyms.  —  Pertussis;  Tussis  Convulsiva. 

Definition.  —  An  acute,  infectious  disease,  characterized  by  the 
gradual  development  of  a  spasmodic  cough  of  peculiar  character, 
signalized  by  a  series  of  explosive  expiratory  efforts  followed  by  a 
long-diawn  inspiration  attended  by  a  peculiar  crowing  sound,  the 
"whoop,"  the  cough  being  preceded  by  symptoms  of  a  common 
cold,  and  followed  by  a  period  of  gradual  subsidence. 

Historical  Note.  —  Whooping-cough  was  described  by  the 
ancient  Greeks  as  bex  theroides.  Old  writers  mentioned  it  as  tussis 
convuhiva.  Cnllen  wrote  of  it  under  the  name  whooping-cough,  and 
described  it  clearly.  Considerable  discussion  was  engaged  in  during 
past  years  as  to  the  character  of  the  disease,  some  claiming  that  it 
arose  from  irritation  of  the  pneumogastric  nerve,  and  others  that  it 
was  caused  by  enlargement  of  the  tracheo-bronchial  glands.  Lin- 
naeus foreshadowed  the  modern  microorganism-theory  of  the  etiology 
of  the  disease  when  he  ascribed  it  to  an  insect.  Later,  Poulet,  Let- 
zerich,  and  Binns  suggested  the  fungoid  nature  of  pertussis. 

Etiology.  —  The  present  knowledge  of  other  infectious  diseases 
renders  it  most  probable  that  this  depends  upon  a  specific  micro- 
organism, which  operates  upon  some  portion  of  the  respiratory 
mucous  membrane.  This  has  not  yet  been  demonstrated  to  the  sat- 
isfaction of  microscopists,  however,  though  several  announcements  in 
the  affirmative  have  been  made.  Thus,  in  1867,  Poulet  found  in  the 
sputa  of  pertussic  patients  minute  bodies  which  he  termed  infusoria, 
and  Letzerich  pro  luced  the  disease  hi  animals  by  inoculating  the 
trachea  with  the  sputa  of  affected  human  subjects,  while  he  asserted 
that  he  found  a  fungus  in  the  secretions  of  the  respiratory  passages. 
Buhl,  Oertel,  and  Hiiter  also  found  them.  The  contagium  is  given 
off  in  the  breath  and  sputa  of  affected  individuals,  and  probably  in 
emanations  of  the  body  as  well,  as  the  disease  undoubtedly  perme- 
ates the  blood.  Children  are  mo.->t  liable  to  the  d.sease,  and  it  usu- 
ally occurs  epidemically,  though  it  may  appear  endemically.  Adults 
occasionally  suffer  from  it.  The  mortality  among  the  children  of 
colored  races  is  stated  by  some  authors  to  be  twice  as  great  as  that 
among  the  white  population.  Clothing  and  rooms  may  be  infected 
so  as  to  convey  the  disease,  in  the  absence  of  an  affected  subject, 


WHOOPING-COUGH.  157 

though  doubtless  the  common  means  of  infection  is  by  direct  conta- 
gion. The  most  common  period  of  life  subject  to  it  is  that  before 
the  third  year,  though  it  sometimes  occurs  during  extreme  old  age. 
Where  the  seasons  are  marked,  spring  and  autumn  seem  to  favor  its 
appearance,  and  it  is  supposed  in  some  quarters  to  be  influenced  by 
measles,  it  often  appearing  quickly  alter  an  epidemic  of  that  disease. 
One  attack  usually  protects  from  a  second.  The  infection  is  believed 
to  persist  for  five  or  six  weeks  after  the  "whooping"  period  has 
passed  off,  the  patient  being  capable  of  communicating  it  during 
that  time. 

Pathology. — The  most  marked  changes  are  found  about  the 
respiratory  organs.  There  is  catarrh  of  the  air  passages — hyperse- 
cretion  of  the  mucous  membrane  of  the  glottis,  larynx,  trachea, 
bronchi  and  their  ramifications — with  congestion  and  hyperplasia. 
Emphysema  is  a  common  condition,  as  well  as  pulmonary  collapse 
—in  fatal  cases.  Capillary  bronchitis  and  pneumonia  frequently 
occur,  leaving  their  traces  in  the  post-mortem  appearances.  There 
is  intestinal  irritation,  evidenced  by  petechial  extravasations  upon 
the  gastric  mucous  membrane  and  wall  of  the  small  intestine;  and 
the  liver  and  spleen  may  be  enlarged  and  fatty.  Hemorrhage  into 
the  subdural  space  sometimes  occurs,  and  more  frequently  there  are 
points  of  extravasation  in  the  brain  and  spinal  cord.  There  is  often 
an  ulcer  under  the  tongue,  by  the  frsenum  linguae,  in  severe  cases, 
due  to  forcible  protrusion  of  the  tongue  against  the  lower  incisors 
during  the  paroxysms  of  coughing.  The  bronchial  and  tracheal 
glands  are  usually  enlarged. 

Symptoms. — After  an  incubation  of  from  seven  to  ten  days,  three 
stages  develop,  viz.,  the  catarrhal,  paroxysmal,  and  stage  of  decline. 

The  catarrhal  stage  resembles  a  common  cold  in  its  characteris- 
tics, there  being  snuffling  of  the  nose  as  in  coryza,  cough,  slight 
feverishness,  peevishness,  and  restlessness  at  night.  The  physician 
may  now  be  requested  to  administer  a  remedy  for  the  "cold,"  and 
upon  doing  so  lie  will  find  that  the  prescription  fails,  and  he  may  be 
applied  to  for  a  more  successful  treatment  a  second  time  before  it 
will  occur  to  him  that  there  must  be  something  more  than  a  common 
cold  that  will  resist  well-proven  remedies  for  such  a  simple  com- 
plaint. The  cough  is  dry  at  first,  but  sooner  or  later  becomes  moist, 
the  secretion  being  a  tenacious,  viscid,  transparent  mucus.  Parox- 
ysmal symptoms  gradually  appear,  aud  the  cough  increases  in  sever- 
ity, the  secretion  being  more  abundant,  the  respirations  shallow,  and 
the  pulse  rapid.  The  duration  of  this  stage  varies  from  three  days 
to  three  weeks,  though  it  usually  lasts  about  ten  days. 

The  spasmodic  stage  is  announced  by  a  paroxysm  terminating  in 


158  SPECIFIC  INFECTIOUS  DISEASES. 

a  pronounced  whoop,  which  settles  the  question  of  the  nature  of  the 
disease,  and  at  the  same  time  ushers  in  a  period  of  severe  suffering 
for  the  patient,  unless  the  affection  be  modified  by  appropriate  treat- 
ment. The  paroxysms  of  coughing  soon  become  peculiar  and  dis- 
tressing. A  whistling  inspiration,  followed  by  a  succession  of  short, 
sharp,  expiratroy  explosions,  announces  the  paroxysm,  the  expiratory 
explosions  continuing  without  inspiration  until  the  patient  grows 
cyanotic  and  exhausted,  and  seems  to  have  lost  the  power  to  fill  the 
lungs  or  stand  upon  the  feet,  the  parent  or  nurse  finding  it  neces- 
sary to  support  the  child,  which  is  completely  relaxed  and  helpless 
in  the  throes  of  the  paroxysm.  The  face  presents  marked  evidence 
of  increasing  venous  stasis,  becoming  more  and  more  cyanotic,  while 
the  eyes  bulge  out,  the  lips  and  cheeks  become  swollen,  the  jugulars 
standing  out  like  blue  cords,  and  the  face  and  limbs  being  covered 
with  perspiration.  The  glottis,  which  is  now  in  a  condition  of  spas- 
modic closure,  finally  opens  partially,  to  permit  the  patient  to  draw 
a  long,  laborious  inspiration,  which  enters  the  glottis  with  a  sharp, 
crowing  sound — the  whoop.  Vomiting  is  now  liable  to  occur,  the 
gagging  serving  to  dislodge  accumulated  mucus.  The  child  is  much 
prostrated  during  the  paroxysm,  and  the  lower  sphincters  may  be  so 
relaxed  that  involuntary  evacuations  occur.  If  the  patient  is  deli- 
cate, it  may  now  fall  into  an  exhausted  sleep,  or,  as  in  most  cases,  it 
may  soon  recover  and  go  about  its  play;  but  it  is  terrified  after  a 
time  by  the  approach  of  another  paroxysm  (which  furnishes  some- 
thing of  a  premonition),  and  may  run  to  its  mother  or  nurse  to  cling 
to  her  for  protection  and  aid.  From  six  to  forty  or  more  of  these 
paroxysms  may  occur  in  twenty-four  hours. 

During  the  paroxysm,  the  thorax  is  dull  on  percussion  during 
expiration,  owing  to  the  contraction  of  the  muscles,  and  remarkably 
resonant  on  inspiration,  the  respiratory  murmur  being  almost  indis- 
tinct on  inspiration  on  account  of  the  small  amount  of  air  admitted 
through  the  chink  at  the  time.  Between  the  paroxysms,  the  respir- 
atory sounds  are  numerous  and  variable.  There  may  be  sonorous, 
sibilant,  and  moist  and  dry  crepitant  sounds  in  the  same  patient, 
predominance  depending  upon  the  amount  and  character  of  pulmo- 
nary complication  that  may  have  arisen.  Bronchitis  is  often  a  com- 
plication, and  where  the  small  tubes  are  affected,  they  are  liable  to 
become  blocked  (capillary  bronchitis)  and  occasion  cyanotic  symp- 
toms and  prostration,  very  much  complicating  the  case. 

During  the  violence  of  the  paroxysms,  numerous  accidents  are 
liable  to  occur;  the  pulmonary  alveoli  may  become  ruptured  and 
permit  of  inflation  of  the  cellular  tissues  of  the  lung  with  air 
(emphysema),  which  may  occasion  serious  results  by  permanently 


WHOOPING-COUGH.  159 

infiltrating  the  part  and  interfering  with  normal  function.  Kupture 
of  cerebral  vessels  with  apoplexy  may  occur,  or  excessive  strain 
to  the  abdominal  mnscles  may  result  in  hernia  or  prolapsus  ani. 

Vomiting  after  the  paroxysms  is  a  common  symptom,  and  this 
may  amount  to  gastric  irritability,  with  habitual  vomiting  of  food, 
tending  to  inanition  and  marasmus.  In  most  cases,  however,  the 
vomiting  is  confined  to  efforts  to  expel  the  tenaci  >us  mucus  which 
accumulates  in  the  throat  during  the  paroxysms,  and  which  is 
removed  with  the  greatest  difficulty,  the  assistance  of  the  nurse's 
finger  often  being  required  to  dislodge  it. 

Conjunctiva!,  cutaneous,  and  pulmonary  extravasations  often  occur 
during  the  paroxysms,  the  eyes  becoming  bloodshot,  and  the  face 
presenting  purple  blotches  of  extravasated  blood,  as  a  result  of  the 
violent  strain  daring  the  act  of  coughing. 

The  nervous  system  is  in  a  condition  of  hyperaesthesia  in  many 
cases,  the  patient  being  excessively  peevish  and  irritable;  cerebral 
congestion,  convulsions,  and  even  permanent  insanity  have  arisen 
during  the  course  of  the  disease. 

After  five  or  six  weeks  from  the  beginning,  the  paroxysms  com- 
mence to  decline  in  severity;  the  whoop  gradually  ceases,  and  the 
case  starts  on  the  road  to  recovery,  though  sometimes  the  paroxysmal 
stage  becomes  chronic,  and  persists  for  a  year  or  more.  In  other 
instances,  whenever  the  patient  may  contract  a  cold,  the  paroxysms 
return  with  considerable  severity  until  after  the  cold  has  been  dis- 
sipated. In  about  nine  weeks  from  the  commencement,  in  ordinary 
cases,  the  paroxysms  and  cough  have  ceased  permanently. 

Complications  and  Sequelae. — The  sequelae  of  pertussis 
occupy  a  prominent  place  in  its  history.  The  persistent  vomiting  may 
give  rise  to  gastro-intestinal  irritation,  followed  by  marasmus  of  per- 
sistent character,  attended  by  muco-enteritis,  from  which  the  patient 
may  rally  with  the  greatest  difficulty,  and  only  under  the  most 
approved  plans  of  treatment. 

Phthisis,  if  latent  in  the  system,  or  if  the  child  be  exposed  to 
contamination,  often  runs  a  rapid  course  after  an  attack  of  whoop- 
iug-cough;  acute  general  tuberculosis  may  develop  also.  Emphy- 
sema and  pneumo-thorax,  as  well  as  broncho-pneumonia,  are  complica- 
tions and  sequelae  to  be  expected,  on  account  of  the  severe  strain 
upon  the  lungs. 

Treatment. — The  treatment  of  pertussis  is  not  usually  applied 
with  very  much  philosophy.  Empirical  prescribing  is  commonly 
resorted  to,  and  this  is  the  best  that  we  can  seem  to  do  with  our 
present  state  of  knowledge.  Though  pathologists  may  agree  that 
the  irritant  is  a  microorganism,  its  exact  location  has  not  yet  been 


160  SPECIFIC  INFECTIOUS  DISEASES. 

decided,  and  if  it  had,  its  destruction  might  involve  the  use  of  rem- 
edies which  would  necessarily  destroy  the  pulmonary  tissues.  If 
ptomaines  are  generated,  there  has  been  little  accomplished  toward 
their  correction  in  the  treatment  thus  far  employed.  Indeed,  old 
school  authorities  content  themselves  (and  blight  the  enthusiasm  of 
their  followers)  by  declaring  that  there  is  little  that  can  be  done 
for  the  disease  except  to  meet  complications  as  they  arise.  A  few 
cases  seem  to  defy  treatment,  it  is  true,  but  others,  and  the  majority, 
can  be  so  modified  that  the  course  of  the  disease  can  be  shortened, 
and  little  danger  or  trouble  arise  from  it. 

Agents  which  exert  the  best  influence  are  adapted  to  the  relief  of 
convulsive  tendencies  arising  from  irritation  of  the  pneumogastric 
nerve,  and  these  are  equally  adapted  to  spasmodic  cough,  whether 
from  pertussis  or  other  provocation. 

Of  the  best  of  these  is  drosera.  It  will  control  a  large  share  of 
the  cases  of  whooping-cough,  and  soon  banish  the  whoop — though  I 
have  used  it  where  its  influence  was  entirely  wanting.  When  this 
proves  to  be  the  case,  the  best  we  can  do  is  to  try  another  remedy. 
Add  from  ten  to  twenty  drops  of  a  reliable  article  of  the  tincture 
(homeopathic,  or  specific  medicine)  to  half  a  tumbler  of  water,  and 
give  a  teaspoonful  every  two  or  three  hours,  in  severe  cases.  If  the 
cough  has  become  pretty  well  established,  it  may  require  a  week  to 
bring  about  the  desired  effect.  If,  by  the  end  of  this  time,  there 
is  no  noticeable  improvement  in  the  cough,  it  will  be  rational  to 
abandon  this  remedy  and  try  another. 

A  remedy  which  has  proven  excellent,  and  which  I  have  found 
prompt  in  relieving  the  severity  of  the  cough,  is  magnesium  phos.,  3x 
trituration.  One  or  two  grains  of  this  may  be  administered  every 
two  hours  during  the  day  until  relief  follows,  the  number  of  doses 
then  being  lessened. 

Where  inflammation  of  the  small  bronchial  tubes,  with  catarrhal 
secretion  (capillary  bronchitis),  arises,  tartar  emetic  3x  trituratiou, 
alone  or  alternated  with  calcarea  phos.,  3x,  will  be  found  excellent, 
calcarea  phos.  being  especially  demanded  where  the  child  is  anaemic, 
and  tending  toward  a  condition  of  marasmus. 

Quinine  inunction,  or  the  internal  use  of  arseniate  of  quinia,  3x, 
may  be  demanded,  where  the  disease  prevails  in  malarious  districts; 
and  sometimes  polymnia  uvedalia  or  grindelia  squarrosa  will  be 
proper  remedies,  on  account  of  splenic  hypertrophy  and  consequent 
congestion  of  the  portal  circulation.  Where  a  condition  of  maras- 
mus is  well  developed  (the  child  having  been  attacked  with  convul- 
sions and  having  entered  upon  a  critical  state),  the  tonic  treatment 
with  faradism,  repeate.l  every  second  day  for  several  weeks,  will 
materially  assist  in  tiding  the  patient  through. 


EPIDEMIC  INFLUENZA.  161 

Cool-tar  products  have  been  highly  extolled  as  remedies  for  the 
convulsive  cough.  I  Lave  known  coal-miners  to  carry  their  children 
into  the  mines  to  remain  all  day,  for  the  purpose  of  arresting  this 
disease,  after  medicines  have  failed;  and  it  is  asserted  that  this 
is  almost  certain  to  succeed.  Antipyrin  is  said  to  be  remarkably 
efficacious  in  many  cases,  iii  doses  of  from  one  to  three  grains.  Phe- 
nacetin  possesses  a  similar  reputation,  though  it  is  not  as  reliable  as 
antipyrin.  Acetanilid  is  less  objectionable  than  antipyrin. 

Castanea  vesca  has  proven  a  satisfactory  remedy,  and  should  not 
be  forgotten  where  stubborn  cases  are  encountered.  Ten  drops  of  a 
tincture  of  the  green  leaves  should  be  administered  every  three  or 
four  hours. 

Bromoform,  in  three-drop  doses  (administered  in  a  swallow  of 
water),  repeated  three  times  daily,  is  reported  as  nearly  a  specific. 

Inhalations  sometimes  prove  beneficial,  and  should  be  resorted  to 
in  such  cases  as  seem  to  defy  other  measures.  The  following  may 
prove  of  service:  R  Essence  of  peppermint  gtt.  x-xx,  carbolic  acid 
gtt.  iii-v,  distilled  water  fi.  M.  Allow  the  patient  to  inhale  from 
a  spray  apparatus,  every  hour.  Or,  a  one  per  cent  solution  of  resor- 
cin  may  be  used  instead. 

Children  recovering  from  whooping-cough  should  be  warmly 
clothed  to  prevent  them  from  taking  cold,  and,  where  recovery  seems 
unduly  protracted,  a  change  of  climate  should  be  advised  whenever 
practicable. 

XIII.  EPIDEMIC  INFLUENZA. 

Synonyms. — Epidemic  Catarrh;  Catarrhal  Fever;  Contagious 
Catarrh ;  French,  La  Grippe ;  German,  Blitz  Catarrh. 

Definition. — Influenza  is  an  acute,  infectious,  epidemic  disease, 
characterized  by  fever,  great  prostration,  severe  pain  in  the  head, 
back,  and  limbs,  marked  nervous  phenomena,  and  catarrh  of  the 
respiratory  and  gastro-intestinal  tract.  The  catarrh  may  be  limited, 
or  affect  all  the  mucous  membranes  to  the  same  extent. 

Historical  Note. — The  name  is  not  descriptive  of  the  disease, 
although,  as  indicating  its  epidemic  character,  it  is  not  inapt  The 
influence  (influenza)  of  the  stars  was  supposed  to  be  causative  and, 
in  the  absence  of  pathological  knowledge,  the  rapid  spread  of  the 
disease  from  continent  to  continent  was  not  unnaturally  ascribed  to 
stellar  influence. 

La  grippe  has  prevailed,  at  intervals,  for  several  centuries,  being 
first  described  in  1323.  Many  of  the  epidemics  are  historical,  such 
as  those  occurring  in  1831,  1847,  and  the  late  epidemic  of  1889-90. 

At  times,  influenza  has  extended  over  almost  the  entire  globe. 

12 


162  SPECIFIC  INFECTIOUS  DISEASES. 

It  has  traversed  the  whole  of  Europe  in  the  space  of  forty  days, 
the  rapidity  with  which  it  travels  being  one  of  its  remarkable  char- 
acteristics, this  probably  suggesting  the  German  name  "lightning." 
It  has  figured  in  the  expression  of  national  dislike  and  jealousy,  as 
the  French  call  it  the  "Italian  fever;"  the  Italians  term  it  the  "Ger- 
man disease ;"  the  Germans  repudiate  this  by  alluding  to  it  as  the 
"Russian  pest;"  while  the  Muscovite  passes  it  along  as  the  "Chinese 
catarrh."  However,  the  majority  of  epidemics  have  originated  in 
Russia. 

Etiology. — Of  the  causative  germs  of  influenza,  we  as  yet 
know  nothing.  Meteorological  conditions  have  but  little  influence 
in  its  production,  and,  although  the  epidemics  usually  occur  in  the 
winter  months,  they  do  not  differ  in  character  from  those  appearing 
in  the  spring  and  autumn.  Damp,  cold,  and  foggy  weather,  which 
would  be  a  prolific  cause  of  colds,  would  help  to  disseminate  it  by 
rendering  the  system  more  liable  to  invasion,  just  as  local  conditions 
tending  to  produce  diarrhoea  and  dysentery  would  favor  the  spread 
of  Asiatic  cholera. 

It  usually  lasts  about  six  weeks,  and  is  severe  in  proportion  to 
the  extent  of  its  prevalency.  No  class  or  age  is  exempt,  although 
children  often  escape  its  influence,  probably  on  account  of  their  not 
being  so  liable  to  exposure. 

Some  of  our  later  investigators  do  not  believe  the  disease  depend- 
ent on  bacteria,  but  ascribe  it  to  an  organism  of  a  different  character. 
The  discovery  of  the  plasmodium  of  Laveran  may  have  pioneered 
the  way  for  the  discovery  of  the  peculiar  microorganism  responsible 
for  the  production  of  the  disease.  One  attack  does  not  confer  immu- 
nity, and  repeated  seizures  are  common. 

Pathology. — There  are  no  special  or  characteristic  pathological 
phenomena,  the  various  lesions  depending  on  the  different  structures 
involved.  If  there  are  marked  gastro-intestinal  symptoms,  the 
mucous  membrane  of  the  stomach  and  bowels  will  be  found  con- 
gested. Except  in  the  rarer  cases  where  there  is  but  little  catarrhal 
inflammation  of  the  respiratory  tract,  we  will  find  it  more  or  less 
pathologically  changed.  The  lungs  are  usually  distended  and  pro- 
truded, instead  of  collapsing,  when  the  thorax  is  opened.  The 
smaller  bronchi  are  much  injected,  the  mucous  membrane,  here  and 
in  the  larger  bronchi,  being  inflamed  and  covered  with  mucus.  A 
softening  and  swelling  of  the  bronchial  glands  is  also  noted.  When 
pericarditis  has  been  a  complication,  we  have  the  usual  anatomical 
changes. 

Symptoms. — La  grippe  manifests  itself  in  all  degrees  of  inten- 
sity, its  clinical  features  depending  on  the  structures  principally 


EPIDEMIC  INFLUENZA.  163 

involved,  and  the  complications  that  ensue.  The  disease  usually 
begins  without  prodromes.  There  is  an  initiatory  chill,  followed  by 
fever  of  a  remittent  type,  ranging  from  101°  to  102°  JF.  The  pulse 
is  not  as  rapid  as  one  would  expect  from  the  fever  present,  although, 
in  serious  cases,  it  may  run  up  to  120  per  minute.  The  urine  is 
scanty  and  high  colored.  With  the  fever,  there  are  splitting  head- 
ache, and  pains  in  the  eyes  and  frontal  sinuses.  The  joints  and  mus- 
cles, especially  of  the  back  and  lower  limbs,  are  racked  with  pain,  of 
a  character  almost  as  excruciating  as  that  noticed  in  dengue  and  vari- 
ola. A  prostration,  far  in  excess  of  that  to  be  expected  from  the 
symptoms,  is  manifested  early,  pathognomonic  of  la  grippe.  Pro- 
fuse sweating  is  usual,  throughout  the  course  of  the  disease.  The 
catarrhal  symptoms  begin  in  the  upper  passages,  and  there  are  pres- 
ent coryza,  hoarseness,  soreness  in  the  pharynx  and  trachea,  and  a 
distressing  cough,  at  first  dry,  but  soon  changing  its  character,  as 
the  secretion  is  increased.  As  the  disease  advances,  the  sputum 
becomes  copious  and  muco-purulent.  There  is  a  constriction  of  the 
chest,  with  difficult  breathing,  prsecordial  oppression,  and  feeble 
cardiac  action,  in  elderly  subjects.  The  involvement  of  the  gastro- 
intestinal mucous  membrane  is  evinced  by  nausea  and  vomiting. 
The  tongue  is  coated,  and  usually  moist.  There  is  constipation, 
which  frequently  gives  place  to  diarrhoea.  In  epidemics  where  the 
digestive  symptoms  are  marked,  dysentery  is  not  uncommon.  There 
may  be  tenderness  over  the  liver,  and  a  jaundiced  condition. 

The  complications  met  with  are  pharyngitis,  laryngitis,  oedema 
aud  congestion  of  the  lungs,  pneumonia,  bronchitis,  pleurisy,  and 
subacute  gastritis.  More  rarely  we  have  congestion  of  the  liver, 
parotitis,  pericarditis,  and  various  cutaneous  disorders.  Pneumonia 
is  the  most  serious  complication.  Copeland  states  that  in  the  epi- 
demic of  1831,  of  the  patients  at  Hotel  Dieu,  over  20  per  cent  had 
lobular  pneumonia. 

Ocular  disturbances  are  among  the  sequelae,  soreness  of  the  ocu- 
lar muscles,  photophobia,  and  retinal  congestion  being  most  com- 
mon. Loss  of  vision  may  occur  from  the  effects  of  this  disease, 
through  retinal  hemorrhage. 

Diagnosis. — Some  of  the  cases  are  liable  to  be  mistaken  for 
"bad  cold,"  but  the  sudden  onset,  great  prostration,  and  catarrhal 
features  are  usually  sufficient  to  demonstrate  a  case  of  influenza. 
After  an  epidemic  is  well  under  way,  no  mistake  should  be  possible. 

Prognosis. — The  prognosis  is  good  in  the  adult  where  the  con- 
stitution is  not  greatly  impaired;  but  the  mortality  is  sometimes 
quite  high  among  children  and  the  aged.  Organic  diseases,  such  as 
parenchymatous  or  intestinal  nephritis,  emphysema,  fatty  heart,  or 


164  SPECIFIC  INFECTIOUS  DISEASES. 

pulmonary  troubles,  render  the  prognosis  more  or  less  doubtful 
The  disease  is  serious  according  to  the  severity  of  the  complications. 

Treatment. — If  we  are  called  early  enough,  an  attempt  should 
be  made  to  abort  the  disease.  If  we  fail  in  our  object,  we  can,  in  a 
great  many  cases,  modify  some  of  the  symptoms,  and  the  patient  is 
no  worse  off  for  the  attempt. 

Diaphoresis  should  be  induced  by  the  alcoholic  vapor  bath,  or 
such  remedies  as  serpentaria  (jss— ji,  p.  r.  n.),  jaborandi  (gtt.  xx— 388, 
p.  r.  n.),  or  the  diaphoretic  or  Dover's  powders  (gr.  v-x,  p.  r.  n.).  A 
hot  pediluvium  should  preface  the  treatment,  and  the  patient  should 
be  well  covered  and  hot  drinks  used,  to  assist  the  diaphoretic  action 
of  the  drugs.  Old  school  physicians  attempt  to  abort  the  disease 
with  large  doses  of  quinine. 

Where  there  is  no  great  depression,  and  in  the  lighter  attacks, 
phenacetin  will  be  a  valuable  remedy;  but  in  serious  cases,  all  depress- 
ing remedies  should  be  avoided.  Phenacetin  modifies  the  fever  and 
relieves  muscular  pain  better  than  slower  acting  remedies.  It  is 
well  to  add  arseniate  of  quinia  3x  to  it  in  most  cases.  Three  grains 
of  the  former  to  two  of  the  latter  every  three  hours,  will  be  the 
usual  dose.  Our  sedatives  can  be  given  alternately  with  the  phenac- 
etin. Aconite  (gtt.  1-6 th),  veratrum  (gtt.  i),  or  gdsemium  (gtt.  i-ii),  will 
be  indicated  for  the  febrile  condition,  the  former  being  preferred 
where  there  is  much  gastro-intestinal  disturbance.  Jaborandi  (gtt.  ii-v) 
may  be  added,  where  the  skin  is  dry.  For  the  muscular  pain,  macro- 
tys  (gtt.  ss)  or  arnica  (gtt.  l-10th)  are  prescribed,  but  the  phenacetin, 
jaborandi,  and  sinapisms  (the  latter  moved  from  place  to  place  as 
required),  will  give  better  satisfaction. 

Milk  should  be  the  principal  diet  for  the  first  few  days,  until  the 
gastric  irritability  passes  away.  For  this  condition,  rhus  tox.  (gtt. 
l-3d)  can  be  added  to  the  sedative.  It  will  also  help  to  relieve  the 
coryza  and  frontal  pain.  A  pack  or  sinapism  over  the  epigastrium 
usually  gives  considerable  relief. 

In  the  treatment  of  the  respiratory  symptoms,  we  are  guided  by 
the  nature  and  extent  of  the  lesion.  Where  the  cough  is  rasping 
and  explosive,  the  trachea  and  its  bifurcations  being  principally 
affected,  bryonia  (gtt.  l-3d)  will  usually  give  relief.  Inula  helenium 
has  been  used  successfully  in  past  epidemics.  Its  effects  are  limited 
to  the  bronchi,  and  by  adding  to  it  asdepias,  we  have  a  powerful 
combination.  They  may  be  given,  aa,  gtt.  v,  in  syrup  and  water, 
every  two  hours,  or  oftener,  if  required. 

In  acute  cough,  with  dryness  and  ticlding,  rhus  tox.  (gtt.  l-3d) 
may  be  prescribed.  It  influences  both  the  circulation  and  the  nerve 
supply,  and  overcomes  that  teasing  and  tickling  which  is  so  annoy- 


DENGUE  FEVER.  165 

ing.  Sticta  (i*tt.  ss-i)  is  a  remedy  that  is  not  serviceable  in  ordinary 
coughs,  but  frequently  does  good  work  in  influenza.  We  do  not  use 
it  where  there  is  abundant  secretion,  but  where  there  is  dryness  and 
wheezing,  the  cough  being  rasping  and  persistent. 

Stannum  6x  will  meet  that  not  uncommon  condition  where  there 
is  a  sense  of  exhaustion  while  speaking,  with  a  tired  sensation  of  the 
larynx. 

Inhalations  of  find,  benzoin  co.  (jss-^i  in  aqua  buL  Oi)  are  grate- 
ful to  the  patient,  and  help  to  relieve  the  catarrhal  condition. 

At  night,  the  cough  can  be  controlled  with  tinct.  serpentaria  co. 
and  glycerine,  aa,  388,  in  hot,  sweetened  water. 

Complications  are  to  be  met  as  they  appear,  the  main  object 
being  to  avoid  depressants,  and  keep  up  the  strength  of  the  patient. 

XIV.  DENGUE  FEVEE. 

Synonyms. — Dengue;  African  Fever;  Dandy  Fever.  When 
this  disease  first  appeared  in  the  British  West  India  Islands,  it  was 
called  the  dandy  fever,  from  the  stiffness  and  constraint  which  it 
gave  the  limbs  and  body.  The  Spaniards  of  the  neighboring  islands 
mistook  the  term  for  their  word,  dengue  (pronounced  deng'ga),  denot- 
ing prudery,  which  also  might  be  considered  as  denoting  stiffness. 
Thus  the  origin  of  the  name.  It  is  also  termed  "break-bone  fever." 

Definition. — A  specific,  infectious  disease,  peculiar  to  warm 
countries,  characterized  by  paroxysms  of  fever,  attended  by  severe 
muscular  and  periosteal  pains,  with  anomalous  eruptions. 

Etiology. — That  this  affection  depends  upon  a  specific  conta- 
gium,  seems  proven  by  the  fact  that  it  has  been  transported  in 
clothing  and  other  fomites  from  distant  parts,  on  the  occasion  of 
more  than  one  epidemic.  Its  first  appearance  in  this  country  dates 
from  the  landing  of  a  cargo  of  slaves  from  Africa.  It  occurs  epi- 
demically and  sporadically,  and  attacks  all  classes  of  people,  from 
infant  to  aged,  rich  and  poor,  in  common.  While  most  liable  to 
break  out  in  southern  latitudes,  it  has  prevailed  in  more  northerly 
sections,  an  epidemic  having  occurred,  according  to  Loomis,  in  Phil- 
adelphia, in  1780.  An  extended  epidemic  occurred  in  the  West 
Indies,  in  1827,  and  one  in  our  Southern  States,  in  1880.  There  is 
some  dispute  among  observers  as  to  whether  the  disease  is  conta- 
gious or  not,  and  as  to  whether  one  attack  provides  immunity 
against  others. 

Dr.  McLoughlin,  of  Texas,  has  discovered  a  microbe,  which  he 
presumes  to  be  the  active  causative  agent  The  organism  is  a  form 
of  streptococcus.  Whether  it  prove  to  be  the  genuine  cause  of 
the  disease  may  yet  be  considered  questionable. 


166  SPECIFIC  INFECTIOUS  DISEASES. 

Pathology. — The  pathology  of  dengue  seems  to  resemble  that 
of  malarial  fever  in  many  respects,  and  it  was  once  believed  to  be  a 
modified  form  of  that  affection.  Arthritic  changes,  similar  to  those 
of  rheumatism,  are  observed  in  some  cases,  though,  as  few  ever 
prove  fatal,  little  is  known  about  the  morbid  anatomy. 

Symptoms. — A  period  of  about  four  days'  incubation  is  followed 
by  an  abrupt  onset,  usually  initiated  by  a  chill,  though  in  children 
convulsions  may  be  the  first  indication  of  its  presence.  The  temper- 
ature now  rises  rapidly,  reaching,  in  some  cases,  as  high  as  107°  or 
108°  F.,  the  pulse  running  at  from  120  to  140  beats  per  minute. 

There  is  severe  frontal  headac/ie  (with  photophobia,  lachrymatiou, 
and  flushing  of  countenance ),  pain  in  the  back,  limbs,  and  joints, 
with  or  without  nausea  and  vomiting.  After  about  twelve  hours,  the 
pains  in  the  limbs,  back,  and  joints  become  very  much  aggravated, 
lancinating  pains  shooting  from  the  lumbar  region  down  the  course 
of  the  sciatic  nerve,  and  along  other  large  trunks.  The  lymphatic 
glands  take  on  inflammatory  action  early  in  the  course  of  the  disease, 
the  swelling  and  tenderness  beginning  in  the  inguinal  glands,  and 
soon  afterward  appearing  in  the  axillae  and  neck,  these  parts  now 
being  exceedingly  sensitive  and  painful.  The  epididymes  are  also 
involved  in  a  similar  state,  becoming  swollen,  sensitive,  and  painful. 
The  muscles  and  soft  tissues  become  tender  to  the  touch,  all  the 
joints  (both  large  and  small)  being  reddened  and  swollen.  The 
fever  continues  unabated  for  from  one  to  five  days,  when  it  termi- 
nates in  crisis.  In  many  cases,  a  transitory,  erythematous  rash  now 
appears,  beginning  on  the  palms  of  the  hands  and  neck,  and  spread- 
ing over  the  entire  body.  This  is  liable  to  appear  about  the  fifth 
or  sixth  day. 

The  decline  of  the  fever,  however,  is  deceptive.  It  is  really 
only  a  remission,  which  lasts  from  two  to  five  days,  when  a  second 
paroxysm  of  fever  occurs,  attended  by  all  the  previous  muscular  and 
arthritic  pains,  headache,  etc.  But  this  paroxysm  is  less  severe 
than  the  first,  and  a  termination  by  crisis  ensues  in  two  or  three 
days,  and  permanent  convalescence  now  follows. 

The  disease  is  very  prostrating  in  its  tendencies,  and  convales- 
cence is  slow,  from  mental  and  physical  debility.  Colliquative 
sweats,  diarrhoea,  and  epistaxis  often  occur  during  the  remission. 

Diagnosis. — Dengue  may  be  confounded  with  remittent  fever, 
as  it  usually  occurs  in  malarious  regions;  but  the  persistency  and 
severity  of  the  muscular  pains,  and  the  glandular  enlargement,  with 
the  cutaneous  eruption,  will  be  distinguishing  features.  The  fever 
preceding  the  arthritic  pains,  and  the  erythematous  rash,  will  dis- 
tinguish it  from  inflammatory  rheumatism,  which  it  resembles;  and, 


DIPHTHEKIA.  167 

if  this  be  not  sufficient,  the  glandular  enlargements  will  be  further 
distinguishing  features.  In  its  course,  it  resembles  relapsing  fever, 
but  it  differs  from  this  in  the  fact  that  it  is  a  disease  of  the  interior, 
while  relapsing  fever  is  a  disease  of  sea-ports,  and  lacks  the  marked 
swelling  of  the  joints  and  lymphatics,  as  well  as  the  eruption,  which 
characterize  dengue. 

Prognosis. — Though  an  apparently  alarmingly  severe  disease, 
the  prognosis  is  almost  always  favorable,  only  those  of  extreme  old 
age,  or  very  young  infants,  succumbing. 

Treatment.  — The  treatment  will  be  directed  toward  a  modifi- 
cation of  the  severe  febrile  disturbance  and  its  accompanying  unpleas- 
antness. A  remedy  especially  adapted  to  the  picture  presented  by 
the  symptoms  is  jdborandi.  This  should  be  given  in  small  doses 
(two  or  three  drachms  to  four  ounces  of  water;  dose,  a  teaspoonful 
every  hour),  repeated  sufficiently  often  to  moisten  the  skin,  control 
the  pulse,  and  lower  the  temperature,  when  the  severe  pain  will  be 
mitigated.  Pliytolacca  may  be  added  for  the  lymphatic  inflammation, 
the  jaborandi  being  combined,  as,  for  instance,  It  Specific  jaborandi 
3111,  specific  phytolacca  ji,  water  fiv.  M.,  order  a  teaspoonful  every 
hour.  When  delirium  is  marked,  gdsemium  or  rhus  fox.,  selected  with 
regard  to  special  indications,  may  be  added  to  the  treatment  already 
prescribed,  or  employed  separately. 

Whenever  practicable,  a  vapor  bath  or  two,  repetition  being  made 
available  of  a  few  hours  after  the  preceding  one,  ought  to  do  much 
toward  relieving  the  force  of  the  onset,  and  conducting  the  case 
through  a  mild  course.  The  alcoholic  vapor  bath  may  do  here, 
though  the  cabinet  vapor  bath  is  preferable,  when  at  hand. 

Attempts  should  be  made  to  modify  the  severity  of  the  pains 
with  macrotys,  rhamnus  californica,  or  phenacetin.  Opiates  may  seem 
to  be  demanded,  but  they  should  be  avoided  in  all  ordinary  cases. 
In  malarious  districts,  the  judicious  use  of  quinine  may  sometimes 
prove  beneficial,  especially  if  periodicity  be  marked. 

Careful  nursing  should  signalize  the  period  of  convalescence, 
until  the  patient  has  regained  his  wonted  vigor. 

XV.    DIPHTHERIA. 

Synonyms. — Angina  Maligna;  Angina  Suffocata.  German, 
Braune  Pruna  (glowing  coal).  Spanish,  Garrotillo. 

Definition. — An  acute,  infectious  disease,  characterized  by  the 
exudation  of  a  membrane  upon  a  recently  irritated  surface — usually 
the  tonsils  and  adjacent  parts — the  membrane  containing  the  Klebs- 
Loffler  bacillus,  the  disease  being  attended  by  blood-poisoning  from 
ptomaines  generated,  resulting  in  profound  prostration  and  anaemia, 


168  SPECIFIC  INFECTIOUS  DISEASES. 

with  liability  to  extensive  pbagedena  of  the  parts  locally  affected,  or 
to  paralysis  of  various  organs  and  muscles,  as  well  as  pulmonary 
complication. 

Historical  Note. — Diphtheria  is  a  disease  which  has  been 
known  from  the  days  of  antiquity.  Asolepiades,  who  lived  one  hun- 
dred years  before  Christ,  performed  laryngotomy  for  the  relief  of 
obstructed  respiration,  and  it  is  therefore  probable  that  he  treated 
membranous  croup  and  diphtheria.  Aretseus,  a  Greek  physician,  who 
lived  at  the  beginning  of  the  Christian  era,  described  mild  and 
severe  cases  of  diphtheria  clearly,  and  Galen,  who  lived  in  the  fol- 
lowing century,  wrote  vividly  of  a  fatal  disease  characterized  by  the 
coughing,  hawking,  and  spitting  of  a  membrane.  Coelius  Aurelianus, 
and  Aetius,  the  latter  of  whom  lived  in  the  fifth  century,  described 
it  also,  in  unmistakable  terms.  No  literature  upon  the  subject 
exists  to  show  that  it  prevailed  during  the  Dark  Ages,  but  this  must 
be  ascribed  to  the  dearth  of  written  records  made  during  that  time. 
It  is  evident  that  it  occurred  in  severe  epidemics  in  the  sixteenth 
century,  and  from  then  to  the  present  day  an  unbroken  chain  of  tes- 
timony exists  to  show  that  it  has  remained  as  one  of  the  most  fatal 
scourges  of  human  life.  It  has  seemed  to  travel  from  the  east  west- 
ward, the  disease  probably  having  been  brought  to  this  country  by 
Europeans.  It  it  believed  that  the  first  cases  occurred  near  Boston, 
about  the  middle  of  the  sixteenth  century  (1638  to  1663).  The  mod- 
ern name  "diphtheria"  was  first  applied  by  Pierre  Bretonneau,  of 
Tours,  France. 

Etiology. — The  disease  is  endemic  to  most  large  cities,  pre- 
vailing epidemically  at  certain  periods.  It  is  not  confined  to  cities, 
however,  it  sometimes  occurring  in  rural  districts,  with  great  viru- 
lence. It  is  contagious,  the  infection  probably  being  communicated 
through  the  membrane,  both  moist  and  dried  particles  being  infec- 
tious, the  virus  possessing  a  remarkable  tenacity  of  life.  Modern 
microscopical  investigators  have  been  inclined  to  the  opinion  formed 
by  Klebs  in  1883,  and  indorsed  more  recently  by  Loffler,  that  the 
active  principle  of  diphtheria  is  a  germ,  found  in  the  diphtheritic 
membrane,  which  is  described  by  bacteriologists  under  the  name 
"Klebs-Lofiler  bacillus." 

This  is  a  non-motile  bacillus,  about  the  third  of  the  diameter  of  a 
red  blood-corpuscle  in  length,  and  about  two  and  a  half  times  as 
long  as  broad.  It  is  rounded  at  each  end,  and  somewhat  enlarged, 
having  a  dumb-bell  appearance.  It  contains  no  spores  that  are  vis- 
ible. It  stains  with  alkaline  methylene  blue,  and  thrives  in  blood- 
serum,  bouillon,  milk,  and  on  raw  potato.  It  is  very  ten.acious  of 
life,  having  been  known  to  retain  its  vitality  for  five  months,  when 


DIPHTHERIA.  169 

the  membrane  was  wrapped  in  a  dry  cloth;  and  when  stained,  it 
resists  the  bleaching  power  of  acids.  The  ptomaine  generated  by 
this  bacillus,  as  w<pll  as  other  septic  processes  arising  from  changes 
occurring  under  the  diphtheritic  membrane,  probably  give  rise  to 
the  grave  symptoms  whiok  often  attend. 

The  most  recent  observations  tend  to  throw  mnch  doubt  upon 
the  identity  of  the  Klebs-Loffler  bacillus  as  the  specific  causal  germ 
of  diphtheria.  In  numerous  instances,  a  similar  microbe  has  been 
found  in  various  situations — in  the  buccal  and  nasal  cavities,  tonsil- 
lar  crypts,  etc. — in  healthy  individuals,  apparently  the  same  kind; 
thus  affording  strong  evidence  of  its  non-malignant  character,  and 
necessitating  further  inquiry  before  the  question  is  fully  settled. 

Sewer-gas  has  been  supposed  to  be  an  active  factor  in  the  cau- 
sation of  the  disease,  but  knowledge  of  the  fact  that  the  virus 
possesses  great  tenacity  of  life,  and  that  it  has  been  common  prac- 
tice to  empty  cuspidors  containing  sputa  of  diphtheritic  patients 
into  the  drains,  will  account  for  contamination  arising  from  sew- 
ers, whenever  traps  are  faulty.  The  fact  that  houses  where  the 
disease  has  been,  remain  points  of  infection  for  so  long,  is  easily 
explained  by  the  knowledge  that  the  virus  retains  its  vitality  for 
a  long  time  when  dried,  and  that  it  may  become  a  portion  of  the 
dust  which  may  finally  settle  upon  the  walls,  to  be  afterward  dis- 
tributed by  a  commotion  in  the  atmosphere,  and  become  implanted 

upon  a  receptive  surface,  such  as  the  sensi- 
tive throat  of  a  child.  Lack  of  caution  in 
the  disposal  of  carpets  and  bedding  which 
have  been  about  a  diphtheritic  patient,  may 
incline  to  the  same  result 

Direct  contamination,  from  one  diphthe- 
ritic  Patient  to  another,  is  also  frequent. 
In  mild  cases,  children  are  often  about  among  their  companions  with 
diphtheritic  throats,  and  the  coutagium  may  carry  death  to  a  sus- 
ceptible person  when  the  one  communicating  it  may  not  be  very 
severely  affected.  Although  it  is  a  disease  which  is  not  very  widely 
diffused  by  one  affected  (a  few  feet  of  distance  affording  safety),  the 
indiscriminate  use  of  drinking  utensils  among  children  of  a  commu- 
nity or  school,  and  especially  among  those  of  a  single  family,  affords 
ready  means  for  the  spread  of  the  disease.  The  fresh  membrane, 
when  implanted  upon  the  mucous  membrane  of  an  unaffected  per- 
son, seems  often  to  possess  particular  virulence;  and  physicans  and 
nurses  frequently  lose  their  lives  by  the  communication  of  the  dis- 
ease from  children,  while  attempts  are  being  made  to  treat  an  affected 
throat,  the  gagging,  coughing,  and  "  spluttering"  of  a  fractious 


170  SPECIFIC  INFECTIOUS  DISEASES. 

patient  serving  to  project  a  particle  of  membrane  with  sufficient  vio- 
lence to  implant  it  upon  some  receptive  mucous  surface  of  the 
operator. 

Animals  are  supposed,  by  good  authority,  to  be  a  medium  of  com- 
munication of  the  disease.  It  is  certain  that  mammals  and  fowls  are 
often  affected  with  rapidly  fatal  diseases,  manifested  principally  by 
membranous  exudation  in  the  throat.  I  have  seen  many  cases  of 
the  kind  among  chickens  in  California,  and  it  is  said  to  be  a 
common  disease  among  other  domestic  fowls.  Calves  and  cats  are 
subject  to  membranous  throat  diseases,  though  it  is  claimed  in  cer- 
tain quarters  that  these  are  not  communicable  to  the  human  family. 
But  it  has  been  observed,  in  several  instances,  that  severe  outbreaks 
of  diphtheria  have  been  preceded  by  such  a  disease  among  fowls, 
when  no  case  of  the  trouble  had  been  observed  for  a  long  time 
before.  The  rapid  flight  of  pigeons — their  wide  circle  of  haunts — 
would  therefore  suggest  a  cause  for  the  distribution  of  the  disease 
to  great  distances  in  rural  communities.  Dr.  M.  W.  Taylor  (London) 
observed  a  case  in  1888,  in  which  a  young  man,  from  no  other  appar- 
ent possible  cause,  was  taken  violently  ill  with  diphtheria  four  days 
after  cleaning  out  a  pigeon-loft ;  and  he  came  to  the  final  conclusion 
that  the  disease  must  have  resulted  from  infection  from  sick  pigeons. 
In  1884,  upon  the  island  of  Skiathos,  off  the  coast  of  Greece,  diph- 
theria appeared,  where  it  had  not  been  known  for  a  period  of  at 
least  thirty  years  before,  under  the  following  circumstances :  During 
that  year  a  dozen  turkeys  were  introduced  to  the  island,  two  of  them 
being  sick  when  they  were  taken  there.  Seven  out  of  the  dozen  soon 
died  with  the  disease,  which  was  evidently  contagious;  three  recov- 
ered, and  two  were  sick  at  the  time  of  the  inquiry.  In  two  of  the 
fowls,  a  pseudo-membrane  was  found  upon  the  laryngeal  mucous 
membrane,  and  in  one  that  recovered  there  was  paralysis  of  the  feet. 
During  the  time  of  the  sickness  of  these  fowls,  diphtheria  arose 
among  the  inmates  of  the  house  adjoining  the  inclosura  in  which  the 
turkeys  were  confined,  the  prevailing  wind  being  favorable  to  waft 
the  emanations  in  that  direction,  and  an  epidemic  of  the  disease 
occurred,  lasting  five  months,  one  hundred  and  twenty  cases  occur- 
ring in  a  population  of  four  thousand,  with  thirty-six  deaths.  Many 
other  instances  are  on  record,  conclusively  proving  that  diphthe- 
ria may  be  communicated  to  the  human  family  through  the  medium 
of  fowls. 

Diphtheria  is  essentially  a  disease  of  children,  and  though  older 
persons  may  be  affected,  the  gravity  of  the  case  usually  depends 
upon  the  age  of  the  patient;  the  younger  the  child,  the  greater  the 
danger,  other  things  being  equal.  It  is  asserted  that  new-born  chil- 


DIPHTHERIA.  171 

dren  possess  a  certain  immunity,  but  this  is  probably  due  to  the 
fact  that  they  are  not  so  liable  to  come  in  contact  with  drinking- 
cups,  spoons,  and  other  utensils  apt  to  be  used  in  common  by  other 
members  of  the  family,  and  are  protected  largely  from  probabilities 
of  outside  contamination.  However,  new-born  children  are  fre- 
quently attacked,  especially  in  hospitals,  and  usually  with  fatal 
result,  the  throat  difficulty  being  attended  or  preceded  by  phlegmo- 
nous  inflammation  of  the  umbilicus. 

While  adults  usually  resist  the  disease  in  ordinary  epidemics  and 
recover,  aggravated  epidemics  occur  where  it  is  fatal  to  nearly  all 
with  whom  it  may  come  in  contact.  Another  circumstance  where  it 
is  singularly  fatal  is  that  where  the  fresh  virus  is  implanted  upon  a 
mucous  surface,  as  often  occurs  to  physicians  while  manipulating 
the  throats  of  children  for  diagnostic  or  therapeutic  purposes.  A 
prominent  physician  of  Oakland  died  within  a  few  days,  a  few  years 
ago,  from  an  accidentof  this  kind  occurring  while  performing  trache- 
otomy upon  a  desperate  case  in  a  child.  Such  cases  are  not  at  all 
uncommon. 

Pathology. — The  disease  manifests  itself  in  a  variety  of  ways. 
A  more  or  less  extensive  destruction  of  tissue  attends  the  location 
of  the  membrane,  this  usually  being  the  fauces,  though  other  parts, 
as  the  nares,  eustachian  tubes,  middle  ear,  larynx,  trachea,  lungs, 
mouth,  oesophagus,  or  stomach,  may  occasionally  be  the  seat  of  the 
exudation.  Occasionally  the  eyes  may  be  the  point  of  destructive 
inflammation,  either  from  extension  of  the  disease  through  the  nasal 
duct,  or  as  the  result  of  direct  contamination.  In  hospital  practice, 
it  has  been  found  that  diphtheria  is  liable  to  locate  itself  upon  the 
raw  surface  left  after  the  operation  of  circumcision,  with  resulting 
destructive  inflammatory  action. 

The  exudation  varies  much  in  extent,  sometimes  covering  but  a 
small  surface,  and  at  others  involving  large  areas,  covering  the  entire 
fauces,  uvula,  and  pharynx,  and  extending  throughout  the  nares,  or 
perhaps  into  the  larynx  and  trachea.  Dr.  J.  Lewis  Smith  records  a 
case  (Keating's  Cyclopaedia)  in  which  a  cast  from  a  considerable 
section  of  the  lower  bowel  was  voided  by  an  adult  patient,  under  his 
observation.  The  thickness  varies  from  the  eighth  of  an  inch  to  as 
much  as  a  third  of  an  inch,  in  some  cases. 

The  cause  of  the  most  severe  and  dangerous  symptoms  is  the 
systemic  poisoning  arising  from  the  ptomaine  generated  by  the  spe- 
cific bacillus,  though  septic  ferments  also  arise  from  pent-up  necrotic 
fluids  confined  under  the  membrane,  in  the  majority  of  cases,  with- 
out doubt,  which  complicate  and  add  to  the  constitutional  gravity 
of  the  disease.  In  some  cases  extensive  sloughing  of  tissue  results 


172  SPECIFIC  INFECTIOUS  DISEASES. 

at  the  point  of  location  of  the  membrane,  but  this  would  not  be  seri- 
ous in  character,  were  it  not  for  the  systemic  effects  of  the  poison. 
In  fact,  the  local  symptoms  cannot  be  considered  a  criterion  of  the 
seriousness  of  the  case,  as  some  which  exhibit  but  slight  local  dis- 
turbance may  result  fatally  in  a  short  time,  from  heart  failure. 

The  diphtheritic  poison  in  the  membrane  induces  a  necrosis  of 
the  cells  with  which  it  comes  in  contact,  and  a  blackened  line  is 
found  about  the  borders  aud  under  the  surface  of  the  exudation  in  a 
few  days  after  its  appearance.  The  superficial  cells  and  leucocytes 
are  first  attacked,  then  the  deeper  structures,  a  coagulative  process 
or  "hyaliue  transformation"  of  the  dead  structures  succeeding,  which 
results  in  the  formation  of  the  leathery  (sometimes  pultaceous)  mem- 
brane. Foci  of  necrosi^  proceed  inward  from  the  surface,  and 
become  localized  in  various  internal  organs,  such  as  the  bronchial 
and  mesenteric  glands. 

When  completed,  the  membrane  is  found  to  consist  of  a  delicate 
interlacing  network  of  fibrin,  containing  epithelial  cells  more  or  less 
altered,  leucocytes,  nuclei,  mucus,  and  amorphous  matter,  as  well  as 
the  Klebs-Loffler  bacillus,  streptococci,  and  staphylococci.  In  a 
few  days  after  its  formation,  decomposition  begins.  During  the 
active  stage  of  the  disease,  the  membrane  reappears  with  remark- 
able rapidity  upon  forcible  removal,  a  few  hours  sufficing  to  replace 
it  entire,  as  firm  and  extensive  as  ever.  When  the  membrane  is 
removed,  a  raw,  bleeding  surface  is  left. 

The  kidneys  and  lungs  are  notably  the  seat  of  pathological  dis- 
turbances in  diphtheria.  Albuminuria  is  a  frequent  complication, 
and  though  this  may  arise  from  feeble  action  of  the  heart,  obstructed 
respiration,  or  fever,  the  direct  action  of  the  diphtheritic  poison  upon 
the  structures  of  the  kidneys,  is  most  apt  to  be  the  cause  of  the 
renal  complication.  We  then  have  parenchymatous  inflammation  of 
greater  or  less  degree,  followed  by  hemorrhagic  infarcts,  glomeru- 
litis,  disseminated  inflammatory  action,  with  cell  infiltration  and  dis- 
integration. The  epithelial  cells  lining  the  tubuli  uriniferi  become 
broken  down  and  separated,  forming  casts.  In  the  lungs  there  are 
evidence  of  pulmonary  apoplexy,  disseminated  extravasations,  capil- 
lary bronchitis,  and  infiltration  of  the  alveoli. 

Capillary  hemorrhage  and  fatty  degeneration  of  the  cells  may 
occur  in  the  liver.  The  spleen  may  be  swollen,  so  as  to  distend  its 
capsule  to  the  utmost,  the  pulp  protruding  upon  rupture  or  slicing  of 
its  covering.  There  is  softening  of  the  pulp,  with  extravasations  of 
blood  into  its  substance  and  hyaline  degeneration  of  its  vessels,  in 
protracted  and  severe  cases.  Extravasation  of  blood  occurs  in  the 
heart,  under  the  pericardial  and  endocardial  surfaces,  with  degenera- 


DIPHTHElilA.  173 

tion  of  the  muscle-nuclei.  The  lymphatic  glands  of  the  carvical  and 
submaxillary  regions  are  swollen,  and  contain  evidence  of  histolog- 
ical  change.  There  are  hypersemia  of  the  cells,  hemorrhagic  points 
in  the  periglandular  tissue,  and  distribution  of  necrobiotic  foci  in 
various  places.  Hyaline  degeneration  is  also  observable  at  various 
points  in  the  glandular  tissue.  The  bronchial  glands  present  evidence 
of  similar  changes. 

The  blood  is  darker  than  normal,  and  there  seems  to  be  a  defi- 
ciency in  the  amount  of  fibrin,  coagulation  being  imperfect.  There  is 
a  notable  increase  in  the  number  of  white  corpuscles,  wi$i  evidence 
of  debris  of  broken-down  red  corpuscles,  as  seen  under  the  micro- 
scope. Extravasation  of  blood  occurs  in  the  brain  and  its  menlnges, 
as  well  as  in  the  lungs,  spleen,  and  kidneys. 

Nature. — The  nature  of  diphtheria  is  peculiar  in  many  respects. 
It  may  be  primary  or  secondary,  usually  occurring  as  a  primary  dis- 
ease, but  infrequently  appearing  as  a  secondary  affection  in  scarla- 
tina, and  occasionally  in  typhoid  fever,  small-pox,  measles,  and 
whooping-cough.  When  it  appears  in  these  diseases,  a  marked 
aggregation  of  symptoms  is  observable,  and  the  membrane  will  be 
found  upon  the  surface  of  some  point  of  irritation — the  fauces  in 
scarlatina,  probably  the  larynx  in  pertussis.  The  complication  is 
a  grave  one,  usually  proving  fatal. 

When  occurring  in  patients  in  whom  there  already  exists  a  local 
inflammation,  the  membrane  usually  appears  upon  the  irritated  sur- 
face. In  scarlatina,  where  the  fauces  are  the  seat  of  irritation,  the 
membrane  is  found  upon  its  appearance.  In  coryza  preceding  a 
diphtheritic  attack,  the  membrane  is  likely  to  be  located  upon  the 
Schneiderian  membrane.  If  conjunctival  irritation  precede  it,  the 
eye  is  liable  to  be  the  point  of  location.  Eye  hospitals  have  been 
notoriously  the  place  of  resort  of  diphtheritic  conjunctivitis.  Cir- 
cumcision of  the  prepuce  among  children  in  hospitals  has  been  so 
frequently  followed  by  the  location  of  diphtheria  in  the  part  after- 
ward, that  it  has  been  considered  advisable  to  substitute  the  opera- 
tion of  stretching  the  prepuce  instead  of  incising  it,  for  the  purpose 
of  avoiding  this  danger.  When  a  blister  is  applied  to  the  surface  of 
the  body  in  a  severe  case  of  diphtheria,  the  abraded  surface  is  soon 
covered  with  membrane  exudate. 

A  point  to  which  much  discussion  has  been  given  is,  Is  diphthe- 
ria primarily  local  or  constitutional?  A  considerable  number  main- 
tain that  the  membrane  forms  first,  and  that  the  ptomaines  are 
afterward  absorbed,  rendering  the  disease  constitutional  after  the 
membrane  has  been  located  for  a  time.  Bnt  it  is  observed  that  the 
membrane  speedily  returns  upon  its  removal  during  the  active  stage 


174  SPECIFIC  INFECTIOUS  DISEASES. 

of  the  disease,  and  it  would  seem  from  this  fact  that  it  is  an  effect, 
rather  than  cause,  of  the  constitutional  state.  The  long  incubative 
period  usual  to  ordinary  cases  also  suggests  constitutional  contam- 
ination prior  to  the  appearance  of  the  membrane.  In  some  cases, 
the  constitutional  symptoms  are  marked  before  the  membrane 
appears.  The  system  succumbs  rapidly  in  severe  cases  before  the 
poison  from  the  membrane  could  apparently  have  time  to  act,  were 
the  constitutional  symptoms  deferred  to  the  time  for  absorption 
from  the  membrane  to  cause  them.  Albuminuria  and  nephritis  are 
often  present  on  the  first  day  in  severe  attacks,  and  it  would  hardly 
seem  that  such  remarkably  rapid  results  could  follow  the  first  appear- 
ance of  the  membrane. 

Symptoms. — The  stage  of  incubation  varies  from  two  to  twelve 
days.  Where  the  disease  is  communicated  by  inoculation,  it  appears 
usually  within  two  or  three  days  after  the  introduction  of  the  virus ; 
where  it  originates  in  the  ordinary  manner,  it  varies  from  seven  to 
twelve  days.  It  is  observable  that  when  the  stage  of  incubation  is 
short  the  disease  is  severe,  while  in  those  cases  in  which  this  is  pro- 
tracted, it  is  mild. 

The  constitutional  symptoms  usually  appear  simultaneously  with 
the  advent  of  the  membrane.  Sometimes  these  are  altogether  absent, 
and  the  local  symptoms  are  all  that  exist  to  indicate  the  presence 
of  the  disease.  There  are  few  cases  which  do  not  exhibit  more  or 
less  constitutional  symptoms  early  in  the  course  of  the  affection. 
The  ordinary  febrile  invasion  often  marks  the  beginning  of  the  dis- 
ease, such  as  chilliness,  followed  by  fever  of  considerable  height,  the 
temperature  rising  to  105°  or  thereabout,  during  the  invasion  stage. 
Sometimes,  in  young  children,  the  disease  is  ushered  in  with  vomit- 
ing or  convulsions.  Where  the  febrile  condition  is  ushered  in  with 
a  chill,  the  temperature  usually  runs  a  higher  course  than  when  the 
disease  comes  on  insidiously.  In  the  former  case,  the  temperature 
is  liable  to  reach  105°  F.  numerous  times  during  the  course  of  the 
disease,  while  in  the  latter  case,  a  temperature  of  103°  F.  is  seldom 
reached. 

There  is  no  correspondence  between  the  local  and  constitutional 
symptoms.  In  some  cases  the  fever  may  be  very  slight  and  the 
membrane  spread  quickly  from  the  start,  with  rapidly  fatal  results, 
while  in  others  the  fever  may  ran  high,  and  the  local  manifestation 
X»e  limited  to  a  small  patch  of  membrane  upon  one  of  the  tonsils. 
The  temperature,  if  high,  is  liable  to  fall,  after  the  first  two  or  three 
days  of  the  disease,  to  near  normal,  and  the  membrane  may  spread 
rapidly,  while  there  is  little  or  no  pyrexial  excitement.  Later, 
however,  there  is  almost  certain  to  be  a  rise  in  the  temperature, 


DIPHTHERIA.  176 

probably  due  to  a  systemic  infection,  different  from  that  of  the  pure 
diphtheritic  virus,  doubtless  from  purulency  developed  about  the 
location  of  the  membrane,  or  from  some  local  inflammatory  action, 
such  as  nephritis,  tonsillitis,  or  pharyngitis. 

But  however  near  normal  the  temperature  may  be  in  marked 
cases,  the  pulse  indicates  profound  constitutional  disturbance,  either 
by  irregularity,  or  pronounced  acceleration  with  feebleness,  or  by 
both.  In  many  cases  the  pulse  will  be  feeble,  small,  and  rapid 
throughout  the  disease,  sometimes,  in  young  children,  running  as 
high  as  170  per  minute.  In  other  cases  it  may  be  rapid  in  the  start, 
but  fall  40  or  60,  within  a  day  or  two.  In  still  ether  cases,  it  may 
be  intermittent  or  remittant  throughout  the  course  of  the  disease, 
suggesting  grave  results  from  the  beginning. 

The  tongue  hardly  ever  presents  evidence  of  morbid  condition  of 
the  stomach  or  circulating  fluids,  as  in  some  other  infectious  dis- 
eases. It  is  usually  moist  and  slightly  furred,  but  commonly  pre- 
sents no  marked  indication  for  remedies  as  suggested  by  specific 
tongue  indications  in  certain  other  cases. 

The  urine  will  often  be  markedly  scanty  early  in  the  disease,  and 
if  it  be  tested  for  albumen,  it  will  be  found  loaded  with  this  sub- 
stance ;  though  renal  complication  is  not  universally  present. 

Local  Symptoms. — Within  twenty-four  hours  after  the  beginning 
of  the  disease,  where  it  affects  the  fauces  or  neighboring  parts,  there 
will  probably  be  found  some  enlargement,  tenderness,  and  redness 
of  the  tonsils ;  and  inspection  of  the  fauces  at  this  time  will  detect 
the  diphtheritic  exudate,  beginning  to  form  over  the  anterior  surface 
of  these  organs,  first  appearing  as  a  small  patch  of  ashen-gray  mem- 
brane probably,  but  spreading  rapidly,  and  often  extending  to  the 
uvula  and  posterior  wall  of  the  pharynx.  At  first  it  may  be  difficult 
to  distinguish  this  from  the  exudate  of  follicular  tonsillitis,  as  this 
may  run  together  from  two  or  more  lacunae  in  some  cases,  and  form 
patches  of  considerable  size.  However,  this  may  be  removed  with- 
out much  difficulty,  while  that  of  diphtheria  is  firmly  attached;  after 
the  membrane  has  spread  upon  the  uvula,  there  can  be  no  confusion 
in  this  direction,  as  the  exudation  of  tonsillitis  is  not  found  except 
upon  the  tonsillar  surface.  The  tonsils  and  fauces  soon  become  con- 
gested and  oedematous,  and  the  cervical  lymphatics  enlarged  and 
painful,  the  neck  being  swollen  and  stiffened.  In  a  few  days,  the 
membrane  becomes  necrotic,  exhaling  an  offensive  odor  and  coming 
off  in  shreds  of  dark  gray  or  black  masses  of  decomposing  material, 
this  occurring,  in  many  cases,  at  the  end  of  a  week.  The  time  of  the 
detaching  of  the  membrane  varies,  however,  and  it  may  remain  two 
weeks  or  more  before  falling  off.  The  surface  covered  by  it  is  raw 
and  bleeding,  after  its  removal. 


176  SPECIFIC  INFECTIOUS  DISEASES. 

The  odor  of  diphtheria,  when  the  case  is  a  severe  one  and  there 
are  marked  putrefactive  tendencies,  is  characteristic,  and  offensive 
in  the  extreme,  resembling  that  of  the  recent  excrement  of  chickens 
most  markedly,  though  exaggerated  and  more  offensive  still. 

There  are  two  varieties  of  diphtheria,  as  regards  the  exudation, 
one  in  which  there  is  a  tendency  to  rapid  development  of  membrane 
without  much  putrefactive  change,  and  another  where  there  is  a  tend- 
ency from  the  start  to  necrotic  changes  in  the  membrane,  and  break- 
ing down  of  tissue,  accompanied  by  offensive  odor  of  the  exhalations, 
without  so  much  disposition  to  rapid  advance.  In  the  first  case,  the 
danger  seems  to  be  principally  that  of  asphyxia,  from  blocking  of 
the  respiratory  passages,  while  in  the  other  it  lies  more  in  the 
extreme  exhaustion  which  soon  results. 

Nasal  diphtheria  is  sometimes  insidious  at  first,  the  membrane 
forming  out  of  sight  in  the  nasal  cavities,  all  the  general  symptoms 
of  the  disease  appearing  without  the  local  evidence  of  the  cause  of 
the  trouble.  It  usually  extends  to  the  pharynx  after  a  time,  the 
membrane  appearing  on  the  posterior  pharyngeal  wall,  or  on  the  pil- 
lars of  the  fauces,  or  tonsils.  It  may  extend  along  the  eustachian  tubes 
and  give  rise  to  inflammation  and  destruction  of  the  middle  ear, 
with  perforation  of  the  membrane.  As  the  exudation  spreads  along 
the  nasal  mucous  membrane,  the  nostrils  become  obstructed,  the 
patient  breathing  through  the  mouth,  and  speaking  in  a  "throaty," 
muffled  tone.  A  sanious  coryza  soon  develops,  which  is  excoriating 
to  the  lip,  and,  as  the  disease  progresses,  epistaxis  frequently  occurs. 
Where  the  membrane  invades  the  eustachian  tubes,  there  is  tinnitus 
aurium  and  sticking  pains  in  the  ear,  aggravated  by  swallowing,  with 
more  or  less  permanent  loss  of  hearing. 

When  the  oesophagus  is  invaded,  there  is  dysphagia,  with  regurgi- 
tation  of  fluids  and  frequent  vomiting,  the  vomited  matter  containing, 
as  the  disease  progresses,  portions  of  membrane.  Later,  portions  of 
the  membrane  may  appear  in  the  stools. 

Sometimes  the  vagina,  rectum,  or  labia  are  invaded,  and  there 
may  be  pain,  tenderness,  swelling,  and  redness  over  the  inguinal 
glands. 

Pharyngeal  diphtheria  may  extend  to  the  larynx  and  trachea,  or 
laryngeal  diphtheria  may  be  developed  independently,  when  the 
membrane  begins  in  the  nares.  It  is  most  apt  to  occur  in  young  chil- 
dren; the  younger  the  child,  the  more  liability  to  this  form  of  the 
disease.  A  croupy  cough  soon  becomes  prominent,  respiration 
being  rough,  and  the  voice  raspy  and  indistinct,  soon  falling  to  a 
whisper.  The  dyspnoea  is  marked,  the  auxiliary  muscles  of  respira- 
tion being  taxed,  paroxysmal  attacks  of  difficult  breathing  occurring 


DIPHTHERIA.  177 

at  frequent  intervals.  The  supra-  and  infra-scapular  spaces  sink 
during  inspiration,  cyanosis  becomes  marked,  and  stupor  or  extreme 
restlessness  becomes  pronounced,  as  dissolution  approaches.  Death 
by  suffocation  finally  results.  Pulmonary  changes  are  evidenced  by 
areas  of  dullness  and  absence  of  the  respiratory  murmur,  with  sub- 
mucous,  subcrepitant,  crepitant,  and  sibilant  rales  intermingled. 
The  epiglottis,  vocal  cords,  and  interior  of  the  larynx  become  com- 
pletely covered  with  exudation,  which,  in  many  cases,  extends  far 
down  the  trachea. 

PARALYSIS. — This  is  a  distinctive  feature  of  diphtheria,  appear- 
ing to  greater  or  less  extent  iii  almost  every  severe  case,  doubtless 
being  the  cause  of  death  in  many  instances  of  heart  failure.  Care- 
ful investigation  of  the  nervous  system  has  been  made,  to  deter- 
mine what  the  pathological  lesions,  if  any,  were,  and  it  has  been 
claimed  by  some  authors  that  degenerative  changes  in  the  nervous 
structures  account  for  the  condition.  Charcot  and  Vulpian,  in  1862, 
detected  granular  degeneration  of  the  nerves  of  the  soft  palate. 
Oertel,  in  1871,  found  extravasations  in  the  substance  of  the  brain, 
spinal  cord,  and  spinal  nerves;  in  one  case  where  death  had  occurred 
from  diphtheritic  paralysis.  Buhl  found  a  similar  condition,  and, 
in  addition,  determined  that  the  nerves  were  thickened  at  their  roots, 
and  that  their  sheaths  were  filled  with  lymphoid  cells  and  nuclei. 
However,  this  does  not  prove  that  diphtheritic  paralysis  is  occa- 
sioned by  such  changes  in  those  who  recover,  and  from  whom 
the  paralysis  spontaneously  disappears  in  a  few  months.  The 
fact  of  speedy  spontaneous  recovery  militates  against  the  proposi- 
tion that  structural  changes  necessarily  operate  in  producing  them. 
It  seems  apparent  that  the  paralysis  may  be  the  result  of  the 
depressing  action  of  the  diphtheria  ptomaine  on  the  functional  activ- 
ity of  the  nerve  centers.  The  most  common  point  of  paralytic  exhi- 
bition, except  the  heart,  perhaps,  is  the  group  of  muscles  about  the 
fauces  and  pharynx.  Difficulty  of  articulation  and  swallowing  are 
here  the  prominent  symptoms,  the  uvula  hanging  down  and  the  epi- 
glottis losing  its  reflex  action,  attempts  at  deglutition  being  attended 
by  the  regurgitation  of  fluids  through  the  nose,  solids  causing  much 
struggling  and  difficulty,  when  attempts  are  made  at  swallowing. 
Paralysis  of  the  laryugeal  muscles,  with  aphonia,  usually  attends 
this  condition.  These  symptoms  come  on  late  in  the  course  of  the 
disease,  when  the  membrane  is  disappearing,  or  a  week  or  ten  days 
afterward.  The  paralysis  of  the  epiglottis  may  endanger  the  lungs, 
through  liability  of  portions  of  food  to  pass  into  the  larynx,  and,  as 
sensation  as  well  as  motion  is  gone,  reflex  coughing  is  not  thus 
excited.  Expectoration  is  impeded,  and  the  pharynx  may  be  blocked 


178  SPECIFIC  INFECTIOUS  DISEASES. 

with  tenacious  mucus,  which  the  patient  lacks  the  power  to  remove. 
As  the  pharyngeal  paralysis  disappears,  other  muscles  of  the 
body  may  become  involved,  the  lower  extremities  being  most  liable 
to  suffer.  There  is  no  regularity  of  the  symptoms,  however,  a  hand 
or  arm,  a  foot  or  leg,  the  muscles  of  the  neck,  the  orbicular  muscles 
or  the  lower  sphincters,  all  being  liable  to  paralysis.  Cardiac  paral- 
ysis is  also  liable  to  occur  during  convalescence,  and  sudden  collapse 
may  take  place  upon  too  sudden  exertion,  many  days  after  the 
patient  seems  out  of  danger. 

However,  paralysis  of  this  kind  usually  subsides  spontaneously, 
time  and  care  being  about  all  that  are  necessary  for  complete  recov- 
ery of  sensation  and  motion  in  the  affected  part. 

The  bowels  seem  to  escape  serious  disturbance  in  this  disease, 
unless,  as  happens  in  rare  cases,  the  membrane  locates  upon  some 
portion  of  the  intestinal  mucous  membrane.  Usually  there  is  no 
disturbance  in  their  functions — a  favorable  condition  for  recupera- 
tion after  the  debilitating  disease  has  spent  its  force,  surely. 

Diagnosis. — The  diagnosis  of  diphtheria  is  not  always  a  simple 
matter.  Pseudo-membranous  exudations  often  occur  upon  the  laryn- 
geal  mucous  membrane  which  are  not  diphtheritic;  for  though  they 
may  cause  death  in  a  short  time  by  asphyxiating  the  patient,  they 
do  not  infect  the  system  with  the  profound  constitutional  poisoning 
of  that  disease,  nor  do  they  present  other  clinical  symptoms  of  diph- 
theria, such  as  the  peculiar  stench,  contagiousness,  and  paralytic 
sequelffi,  when  recovery  results.  Also,  bacteriologists  are  somewhat 
confused  as  regards  the  evidence  afforded  by  the  Klebs-Loffler  bacil- 
lus, as  it  is  asserted  that  there  are  cases  of  angina  attended  by  an 
exudation  which  contains  a  bacillus  identical,  morphologically,  and 
in  its  behavior  on  culture,  with  this  germ,  which  does  not  communi- 
cate diphtheria  when  inoculated. 

Clinical  characteristics  are  the  best  criterion  by  which  to  deter- 
mine the  identity  of  the  disease,  in  general  practice.  The  extreme 
prostration,  the  markedly  feeble  and  rapid  pulse  from  the  start,  the 
putrid  odor,  in  conjunction  with  the  characteristic  leathery  mem- 
brane, can  hardly  be  mistaken  for  any  other  disease,  even  if  it  should 
be  attended  by  angina  with  a  pseudo-membrane.  In  large  cities, 
where  diphtheria  has  become  established  ( and  this  is  the  case  with 
almost  any  city  possessing  a  sewerage  system),  the  chances  are  all  in 
favor  of  any  angina  attended  by  the  formation  of  a  leathery  mem- 
brane in  the  throat  being  diphtheria.  The  exceptions  are  certainly 
rare,  and  are  only  worthy  of  notice  to  complete  the  requirements  of 
a  text-book  on  practice.  Pseudo-membranous  croup  lacks  the  pros- 
tration that  marks  true  diphtheria,  is  not  attended  by  the  rapid,  fee- 


DIPHTHERIA.  179 

ble  pulse,  and  is  free  from  the  stench  that  characterizes  disintegra- 
tion of  the  diphtheritic  membrane. 

Prognosis. — The  prognosis  of  diphtheria  is  always  doubtful 
when  the  poison  is  sufficiently  intense  to  markedly  disturb  the  vital 
functions.  Even  though  the  membrane  may  not  be  extensive,  the 
constitutional  effects  may  result  seriously,  as  there  are  so  many  ave- 
nues open  to  a  fatal  result.  If  the  prostration  be  not  marked  at  first, 
there  is  always  a  possibility  that  the  kidneys  may  become  involved 
so  seriously  as  to  destroy  the  patient.  Then,  if  this  danger  be  past, 
there  is  still  danger  that  heart  failure  may  suddenly  terminate  the 
case.  It  being  a  treacherous  and  uncertain  disease,  care  must  be 
observed  nob  to  pronounce  too  favorably,  in  any  event. 

It  is  to  be  remembered,  however,  that  there  is  great  difference  in 
the  character  of  different  epidemics,  and  that  a  prognosis  may 
depend  considerably  upon  the  epidemic  influence  at  hand.  Mild 
epidemics  are  attended  by  small  mortality,  and  the  treatment  that 
seems  to  make  little  impression  in  severe  cases  may  suffice  at  such 
times. 

The  age  of  the  patient,  also,  will  exert  an  important  bearing  upon 
the  prognosis,  the  younger  the  subject  the  greater  the  danger  of  lar- 
yngeal  complication,  probably  one  of  the  most  serious  conditions 
liable  to  attend. 

The  period  of  the  disease  determines  to  a  certain  extent  the  char- 
acter of  the  danger.  During  the  first  six  or  seven  days  laryngeal 
complication,  or  septicaemia,  is  most  liable  to  appear.  The  voice 
should  now  be  watched,  to  determine  whether  it  becomes  husky  or 
croupy.  A  throaty  voice,  with  snuffling  breathing,  will  suggest  nasal 
complication,  another  portentous  sign,  as  such  cases  seldom  recover. 
Bapid  prostration,  with  lividity  of  countenance,  delirium,  or  tendency 
to  drowsiness,  especially  if  the  pulse  be  irregular  and  the  tempera- 
ture elevated,  will  suggest  septicaemia.  After  the  first  six  or  seven 
days,  inflammatory  complications,  if  these  exist  (such  as  nephritis  or 
tonsillitis),  have  become  fully  developed,  and  the  danger  may  now  be 
in  this  direction.  Or,  at  this  time,  sudden  death  by  syncope  is  lia- 
ble to  result  from  heart-clot,  or  abrupt  arrest  of  cardiac  action  from 
other  causes.  After  the  second  week,  nervous  symptoms,  especially 
paralysis,  may  be  expected,  though  if  the  patient  has  reached  this 
period,  the  prognosis  may  be  considered  more  favorable,  as  the  par- 
alytic symptoms  are  not  liable  to  prove  fatal  unless  the  heart 
becomes  involved. 

Treatment. — The  patient  should  be  isolated,  and  a  strict  quar- 
antine established  between  the  sick-room  and  all  outsiders,  except 
the  nurses  and  physician.  Carpets  and  superfluous  fomites,  such  as 


180  SPECIFIC  INFECTIOUS  DISEASES. 

rugs,  lace  curtains,  and  extra  bedding,  should  be  removed.  Dis- 
charges from  the  mouth,  throat,  or  other  parts  liable  to  contain  diph- 
theritic matter,  should  be  disinfected  with  a  strong  solution  of 
corrosive  sublimate  before  being  emptied,  and  then  should  be  buried 
in  a  trench  dug  for  the  purpose;  or,  when  possible,  it  should  be 
received  from  the  patient  on  cloths,  these  to  be  immediately  burned. 
A  basin  of  weak  carbolic-acid  solution  should  be  near  the  bed  for 
washing  the  sponges,  etc.,  used  about  the  patient,  and,  instead  of 
pocket  handkerciefs,  cloths,  which  may  be  immediately  burned,  should 
be  employed.  Care  should  be  observed  to  keep  all  feeding-cups, 
glasses,  and  spoons  separate,  and  these  should  be  cleansed  in  an 
antiseptic  solution  before  being  allowed  to  leave  the  room,  to  be 
washed.  Linen,  over  a  piece  of  waterproof  made  into  a  bib,  to  pin 
over  the  nightdress  of  the  patient,  will  serve  as  a  protection  against 
the  irritation  of  the  neck  and  throat  'from  the  acrid  discharges  which 
are  liable  to  excoriate  the  skin,  if  coming  in  contact  with  it. 

At  the  termination  of  the  case  the  room  and  its  contents  should 
be  thoroughly  fumigated  by  burning  sulphur,  the  air  in  the  room 
being  moist  at  the  time,  or  else  the  walls  and  floor  should  be  dili- 
gently scoured  with  a  strong  solution  of  corrosive  sublimate,  and  the 
bedding  and  other  clothing  well  boiled  in  a  carbolic  solution. 

When  possible,  experienced  nurses  should  be  in  charge  of  every 
case  of  diphtheria,  as  intelligent  precautions  against  the  spread  of 
the  disease  are  as  important  as  attention  to  the  patient  in  hand;  and 
the  life  of  the  patient  may  depend  largely  upon  proper  care  at  such 
times,  especially  after  the  operation  of  tracheotomy,  prompt  feed- 
ing and  other  details  now  being  especially  important. 

Physician  and  nurse  should  be  careful  about  keeping  the  mouth 
closed  while  standing  over  the  patient,  and  in  treating  the  throat  or 
making  examinations  it  is  wise  to  wear  a  mask  or  silk  handkerchief 
over  the  mouth  and  nose,  as  a  safeguard  against  accidental  infec- 
tion. The  hands  of  the  attendant  should  be  cleansed  frequently,  in 
disinfectants,  those  of  the  physician  especially  before  leaving  the 
room  after  examining  the  patient,  and  those  of  the  nurse  especially 
before  taking  meals. 

It  is  an  excellent  plan  to  see  that  the  room  is  constantly  perme- 
ated with  steam  from  an  antiseptic  and  aromatic  solution.  The  fol- 
lowing prescription  is  highly  recommended  by  Dr.  J.  Lewis  Smith, 
and  I  have  used  it  with  considerable  satisfaction :  ^  Carbolic  acid 
and  oil  of  eucalyptus,  aa,  fi;  spirits  of  turpentine,  fviii.  This  should 
be  mixed,  and  a  tablespoonful  of  it  mixed  with  a  quart  of  water 
for  use,  in  a  shallow  vessel,  which  is  kept  constantly  simmering  upon 
a  gas  or  keroseue  stove.  This  tends  to  soften  the  exudation  and 


DIPHTHEKIA.  181 

encourage  secretion  of  the  mucous  membranes,  thus  assisting  in 
throwing  it  off. 

Ventilation  must  not  be  neglected,  as  it  is  especially  important 
here,  on  account  of  rapid  vitiation  of  the  air  from  putrescent  odors 
and  emanations. 

It  should  be  remembered  that  syncope  and  sudden  death  are  not 
uncommon  in  this  disease,  and  that  the  upright  position  is  inclined 
to  promote  such  an  accident.  The  recumbent  posture  is  the  safe  one 
for  the  patieut  until  convalescence  is  well  established.  I  have  known 
of  several  cases  where  dangerous  syncope  resulted  from  incautious 
getting  up  before  the  disease  was  fully  under  control,  and  even  dur- 
ing early  convalescence. 

The  medicinal  treatment  of  diphtheria  is  still  very  unsatisfactory 
in  its  results.  It  is  true  that  many  mild  cases  seem  to  do  well  on 
aconite  and  phytolacca,  but  these  would  probably  recover  if  left  alone 
therapeutically,  and  carefully  nursed.  Doubtless  phytolacca  relieves 
the  congestion  about  the  fauces  to  a  certain  extent,  and  is  therefore 
of  some  use — this  being  its  specific  province;  and  it  will  be  called 
for  where  there  is  considerable  tonsillitis.  But  when  we  encoun- 
ter severe  cases,  we  are  frittering  valuable  time  away,  when  we 
depend  upon  it,  in  the  least,  as  a  remedy  for  diphtheria,  as  its  effects 
can  be  but  illusory.  The  " special  sedatives"  are  also  subject  to 
objections,  as  they  can  exert  little  or  no  control  over  the  course  of 
the  disease,  and  though  pyrexial  action  be  present,  it  is  not  so  det- 
rimental as  the  after-effects  of  any  remedy  which  can  act  as  a 
cardiac  depressant  in  minute  doses,  where  there  is  so  much  inev- 
itable prostration.  Aconite,  veratrum,  gelsemium,  and  jaborandi 
should  be  tabooed  here,  as  there  is  no  rational  room  for  their 
exhibition.  If  a  sedative  remedy  is  to  be  employed  especially  for 
its  sedative  effects,  there  can  be  no  objection  to  ferric  phos.  3x,  which 
is  very  reliable  for  the  general  purposes  of  a  sedative,  and  cannot 
produce  bad  results.  The  markedly  anaemic  condition  would  rather 
favor  the  theory  of  its  application. 

We  seldom  find  the  antiseptic  propositions,  manifested  by  the 
tongue,  which  are  found  in  some  other  acute  infectious  diseases. 
The  gastro-iutestinal  canal  does  not  seem  to  become  sufficiently  dis- 
turbed to  develop  marked  tongue  symptoms,  and  when  the  disease 
is  ushered  in  by  vomiting,  it  is  usually  caused  by  an  effect  upon  the 
nervous  centers  produced  by  the  diphtheritic  poison,  rather  than  by 
morbid  accumulations  or  local  irritability.  I  have  never  yet  seen  a 
case  where  the  sulphate  of  sodium,  rhus  tox.,  sulphurous  acid, 
hydrochloric  acid,  or  any  other  specifically  tongue-indicated  anti- 
septic was  pronouncedly  called  for.  Where  this  was  the  case,  I 


182  SPECIFIC  INFECTIOUS  DISEASES. 

should  administer  the  proper  one  with  faith  that  some  good  might 
be  accomplished.  Chlorate  of  potassium  has  seen  its  day,  as  the 
common  complication  of  nephritis  is  well  recognized,  and  also  the 
fact  that  this  drug  is  very  liable  to  produce  a  similar  condition 
without  other  causes.  It  is  so  detrimental  as  to  be  considered  dan- 
gerous, by  modern  therapeutists.  The  disease  is  necrotic  in  its  tend- 
encies, and  should  not  be  furthered  in  its  effects  by  strong  chemicals 
which  are  liable  to  favor  destruction  of  red  blood-corpuscles  and 
fibrin,  as  well  as  firmer  structures. 

Probably  we  at  present  possess  but  two  or  three  ideal  remedies 
for  diphtheria;  and,  unfortunately,  they  are  not  always  successful. 
However,  echinacea  combines  nearly  all  the  properties  desirable  for 
the  fulfilling  of  the  most  important  indications  in  the  treatment  of 
this  disease,  as  an  internal  agent.  It  is  a  sedative,  while  it  stimu- 
lates the  vital  forces  at  the  same  time.  It  is  eminently  antiseptic 
and  anti-necrotic.  Furthermore,  it  is  undisputably  harmless  in  its 
effects.  There  can  be  no  danger  in  saturating  the  system  with  it, 
and  this  should  be  done  throughout  the  disease,  unless  there  be 
some  prominent  call  for  another  remedy,  the  action  of  which  might 
be  embarrassed  by  it.  In  all  cases  where  septic  and  necrotic  tenden- 
cies are  prominently  marked,  ten  or  fifteen  drops  of  specific  medi- 
cine, or  green-plant  tincture,  every  hour,  to  a  child  eight  years  of 
age,  will  be  demanded.  Where  it  is  desirable  to  obtain  the  effect  of 
some  other  remedy,  this  should  be  employed  as  an  intercurrent, 
throughout  the  treatment. 

Another  remedy,  which  is  better  adapted  to  many  cases,  on 
account  of  its  superior  action  in  cardiac  failure,  is  lachesis,  an  agent 
which  has  made  many  cures  of  severe  diphtheria.  My  attention  was 
called  to  it  many  years  ago,  under  the  following  circumstances: 
A  severe  epidemic  broke  out  in  a  neighboring  township,  while  I 
was  practicing  in  the  country,  and  proved  to  be  remarkably  malig- 
nant in  character,  being  fatal  in  almost  every  case  affected;  and  it 
did  not  cease  until  entire  households  were  eradicated,  adults  and 
children  in  common,  though  it  was  confined  to  a  small  neighborhood. 
Several  families  employed  old-school  physicians,  but  at  last  the  dis- 
ease entered  a  family  of  homeopathic  proclivities,  and  a  young  homeo- 
path, who  had  recently  located  in  the  neighborhood,  was  called. 
There  were  several  members  in  this  family,  but  all  recovered  except 
one,  which  was  considered  a  remarkable  circumstance,  as  the  disease 
completely  swept  away  several  families  which  had  been  treated  by 
allopaths.  In  conversation  with  the  homeopath  afterward,  I  learned 
that  he  had  depended  almost  entirely  on  lachesis,  in  the  treatment 
of  his  cases. 


DIPHTHERIA.  183 

The  remedy  is  so  well  adapted  to  this  disease  that  I  will  reprint, 
from  Hughes'  Manual  of  Pharmacodynamics,  an  extract  bearing  on 
its  action,  both  in  this  disease  and  others  attended  by  local  gangrene 
and  systemic  infection : 

"Malignaut  local  inflammation,  with  secondary  blood  infection 
and  nervous  prostration,  have  proved  preeminently  the  sphere  of 
lachesis.  A  typical  instance  is  traumatic  gangrene.  Of  this  dis- 
ease Dr.  D.  M.  Dake  has  published  three  cases,  which  are  so  decisive 
as  to  overcome  even  Dr.  Hempel's  skepticism  as  to  the  virtue  of  the 
remedy.  They  are  given  at  length  in  the  second  edition  of  his 
Materia  Medica ;  and  in  the  fourth  volume  of  the  American  Homoeo- 
pathic Review  Dr.  Searle,  of  Brooklyn,  has  recorded  two  others.  To 
these  I  would  add  the  testimony  of  Dr.  Franklin,  who,  as  army 
surgeon  in  the  late  civil  war  in  America,  had  abundant  opportunity 
of  seeing  the  disease.  'I  have  used  this  remedy,'  he  writes  in  his 
Science  and  Art  of  Surgery,  'in  a  number  of  cases  of  gangrene  follow- 
ing wounds,  and  have  never  been  disappointed  in  its  results.  In  a 
case  of  comminuted  leg  fracture,  terminating  in  gangrene  and  threat- 
ening speedy  destruction  of  the  limb,  the  gangrene  was  quickly 
checked  by  the  internal  and  external  use  of  lachesis,  the  inflamma- 
tion subsiding,  and  the  healing  process  moving  on  to  a  complete  cure. 
In  another  case  of  compound  dislocation  of  the  ankle-joint,  with  frac- 
ture of  malleolus  externus,  followed  by  gangrene,  lachesis  effected  a 
speedy  cure,  the  patient  making  a  good  recovery  under  the  surgical 
treatment  employed.  I  cannot  recommend  too  highly  the  use  of 
this  agent  for  gangrene,  and  am  confident  that  the  observations  of 
all  who  have  employed  or  may  employ  it  will  bear  me  out  in  the 
assertion  that  it  is  eminently  curative  of  gangrenous  affections.' 

"It  is  affections  of  this  kind,  moreover,  which  form  the  bulk  of 
the  paper  of  Dr.  Carroll  Dunham,  to  which  I  have  referred.  He 
begins  with  a  case  of  septicaemia  occurring  in  his  own  person,  as  the 
result  of  a  wound  incurred  during  the  post-mortem  examination  of  a 
case  of  puerperal  peritonitis.  Both  the  local  and  general  symptoms 
were  severe,  but  they  rapidly  yielded  to  lachesis  12,  three  times  a 
day.  Next  he  relates  an  epidemic  of  malignant  pustule,  in  which  he 
treated  eight  cases  with  lachesis  alone.  'It  relieved  the  pain  within 
a  few  hours  after  the  first  dose  was  given,  and  the  patients  all 
recovered  very  speedily.'  Then  he  speaks  of  three  cases  of  phlebitis 
supervening  upon  ulcers  (probably  syphilitic)  of  the  lower  extrem- 
ities. There  was  great  and  sudden  prostration  of  strength,  low  mut- 
tering delirium,  and  general  typhoid  symptoms,  indicating  pyaemio 
infection.  The  effect  of  lachesis  was  all  that  could  be  desired,  the 
patient  rallying  promptly,  and  all  symptoms  of  phlebitis  speedily 


184  SPECIFIC  INFECTIOUS  DISEASES. 

disappearing.  Last,  he  narrates  one  case,  and  refers  to  others,  of 
carbuncle,  in  which  the  constitutional  symptoms  denoted  very  great 
prostration,  not  preceded  or  attended  by  the  nervous  and  vascular 
erethism  which  is  sometimes  observed  in  similar  cases.  The  absence 
of  this  condition,  he  thinks,  in  all  these  disorders,  the  indication  for 
luchesis  as  against  arsenicum,  when  the  asthenia  is  not  so  complete 
as  to  call  for  carbo  vegetabilis. 

"Dr.  Dunham  finally  refers  to  the  usefulness  of  lachesis  in  cer- 
tain cases  of  diphtheria.  In  these  the  tumefaction  of  the  throat  was 
slight,  and  the  redness  of  the  mucous  membrane  hardly  noticeable, 
the  diphtheritic  deposits  consisting  merely  of  two  or  three  patches 
hardly  larger  than  a  pin's  head.  But  the  prostration  of  strength 
was  quite  alarming;  the  pulse  became,  in  a  very  short  time,  slow, 
feeble,  and  compressed;  a  cold,  clammy  sweat  frequently  covered 
the  forehead  and  extremities;  the  breath  was  foetid;  the  appetite 
entirely  destroyed.  'In  such  cases,'  he  writes,  'in  all  in  which  the 
constitutional  symptoms  thus  predominated  over  the  local,  lachesis 
produced  prompt  and  lasting  improvement,  so  much  so  that  very 
rarely  was  any  other  remedy  given  subsequently.'  To  the  same 
effect  is  the  testimony  of  Dr.  Tietze,  of  Philadelphia,  in  the  fourth 
volume  of  the  United  States  Medical  and  Surgical  Journal.  He  men- 
tions a  purple,  livid  color  of  the  affected  parts,  with  dull,  dry 
appearance  and  little  swelling,  also  pain  out  of  all  proportion  to  the 
amount  of  inflammation,  as  local  characteristics  of  the  remedy.  He 
places  it  third  to  belladonna  and  apis  in  throat  affections,  in  the 
descent  from  sthenic  to  asthenic  conditions.  Dr.  E.  M.  Hale  also 
contributes  to  the  American  Journal  of  Homoeopathic  Materia  Medica 
three  similar  cases  of  diphtheria  in  children,  which  made  a  rapid 
recovery  under  lachesis,  while  the  rest  of  the  family  (altogether 
eight  in  number)  under  old-school  treatment  succumbed  to  the 
disease." 

In  using  this  remedy,  I  prescribe  two  or  three  grains  of  the  6x 
trituration,  to  be  repeated  every  two  hours. 

But  there  is  a  form  of  diphtheria  in  which  the  tendency  to  early 
putrefaction  and  necrosis  is  not  so  marked  as  that  of  rapid  spread 
of  the  membrane.  We  hore  have  the  danger  of  blocking  of  the  lar- 
ynx with  exudate  to  encounter,  especially  in  young  children;  and 
neither  echinacea  nor  lachesis  seems  to  possess  the  property  of  con- 
trolling plastic  exudation.  Potassium  chlor.  3x  comes  nearer  ful- 
filling this  requirement  than  any  other  remedy  we  know  of,  and 
Schuessler  has  been  very  enthusiastic  over  its  action  as  a  specific  for 
diphtheria,  on  this  account  It  certainly  is  of  considerable  service 
in  this  particular  class  of  cases,  as  I  know  from  experience,  and  here 


DIPHTHEEIA.  185 

we  will  administer  echinacea  or  lachesis  every  three  or  four  hours, 
and  give  potassium  chlor.,  adding  ten  grains  of  the  3x  to  half  a  glass 
of  water;  dose,  a  teaspoonful  every  hour. 

There  are  many  other  remedies  which  have  been  advocated  for 
the  internal  treatment  of  diphtheria,  such  as  sulpho-carbolate  of  sodium, 
benzoale  of  sodium,  pilocarpine,  turpentine,  eucMorine,  tincture  chloride 
of  iron,  etc.  The  numerous  remedies  recommended  by  different 
authors  are  suggestive  of  the  fact  that  few  of  them  possess  the 
required  virtues,  when  desperate  cases  are  encountered.  However, 
a  careful  study  of  these  is  recommended,  lest  something  useful  be 
neglected. 

The  use  of  alcoholic  stimulants  throughout  the  disease  is  an  old 
practice,  but  some  adhere  to  it  at  the  present  day.  Mild  cases  will 
recover  under  such  treatment,  doubtless,  as  they  will  recover  sponta- 
neously ;  but  as  alcohol  does  not  cure  anything  else,  it  is  difficult  to 
believe  that  it  will  cure  severe  cases  of  diphtheria.  Happily,  it  is  not 
so  fashionable  a  remedy  as  formerly,  and  one  can  now  omit  it  from 
his  treatment  without  losing  caste  among  his  allopathic  neighbors. 

The  local  treatment  of  the  membrane  is  an  important  matter,  at 
least  is  so  considered,  as  this  is  liable  to  be  the  nidus  of  septic  accu- 
mulation, and  the  source  of  septicaemia  infection,  quite  independently 
of  the  original  diphtheritic  virus.  To  abridge  the  extent  of  this  for- 
mation, lessen  its  thickness,  and  render  it  as  little  septic  as  possible, 
seem,  then,  important  considerations.  These  are  to  be  accomplished 
by  the  use  of  solvent  antiseptics,  such  as  lime-water,  pepsin,  trypsin,  pap- 
yotin,  and  peroxide  of  hydrogen,  as  well  as  many  others  not  here  men- 
tioned. The  douche  may  be  used  to  irrigate  the  nasal  cavities  in  nasal 
diphtheria,  though  too  much  of  this  is  liable  to  bring  on  inflamma- 
tion of  the  middle  ear. 

Swabbing  of  the  throat  has  fallen  into  disrepute  in  many  quar- 
ters, as  the  struggles  of  the  patient  in  resisting  the  operation,  for 
which  many  children  entertain  a  great  horror,  are  liable  to  result  in 
blind  and  forcible  efforts,  which  irritate  the  tender  and  partially  dis- 
organized structures,  inviting  the  deposition  of  more  membrane,  and 
aggravate  what  inflammation  may  already  be  present.  Atomization 
of  fluids  with  a  spray  apparatus  is  the  best  method  of  application, 
the  remedies  being  employed  in  solution. 

The  following  combination  affords  good  satisfaction,  the  throat 
being  sprayed  with  it  frequently :  R  Glycerine  gtt.  xx,  carbolic  acid 
gtt.  xv,  aqua  f  i,  essence  of  peppermint  jiss.  Misce.  Or,  R  Oil  of 
eucalyptus  f ii,  beuzoate  of  sodium  31,  bichromate  of  sodium  ^ii,  glyc- 
erine f  ii,  lime-water  Oi.  Misce.  These  may  be  used  both  for  nasal 
and  pharyngeal  exudation. 


186  SPECIFIC  INFECTIOUS  DISEASES. 

Where  the  laryngeal  exudation  becomes  so  abundant  as  to  impede 
the  respiration,  and  is  evidently  advancing,  tracheotomy  or  intuba- 
tion should  be  resorted  to  early,  before  the  patient  has  become  so 
exhausted  as  to  render  the  effort  useless. 

Inflammatory  conditions  must  be  met  by  proper  special  reme- 
dies. Tonsillitis  may  demand  phytolacca;  inflammation  of  the  mid- 
dle ear,  piper  methysticum  or  pulsatilla;  nephritis,  rhus  aromatica 
or  vesicaria  commuuis. 

The  paralysis  may  be  benefited  somewhat  by  the  proper  applica- 
tion of  galvanism  and  the  internal  use  of  nerve  stimulants,  but  time 
usually  relieves  such  conditions  nearly  as  rapidly  as  treatment,  and 
if  patient  and  friends  are  assured  that  a  favorable  outcome  may  be 
expected,  this  symptom  will  not  cause  much  trouble. 

The  food,  during  the  disease  and  during  convalescence,  should  be 
of  the  most  nutritious  character,  and,  at  the  same  time,  of  a  kind  to 
be  easily  swallowed  and  digested.  Meat  juice,  malted  milk,  beef 
peptonoids,  and  plain,  fresh  milk  may  all  be  resorted  to,  as  is  most 
convenient  and  acceptable.  Food  should  be  given  in  small  quantity, 
often,  as  it  is  to  be  remembered  we  are  dealing  with  a  rapidly  pros- 
trating affection.  Cathartics  should  be  avoided,  as  they  embarrass 
digestion,  and  derange  the  functions  of  the  alimentary  canal. 

Time  has  favored  belief  in  the  antitoxine  treatment,  in  desperate 
cases.  There  is  no  doubt  that  the  injection  of  the  substance  into 
the  circulation  is  fraught  with  considerable  danger,  for  numerous 
cases  are  on  record  where  it  has  been  employed  for  prophylaxis, 
in  which  sudden  death  was  the  result.  But,  again,  it  has  been  fol- 
lowed by  favorable  changes,  where  death  seemed  imminent,  and  it 
seems  indisputable  that  in  its  proper  place'it  is  sometimes  surpris- 
ingly efficacious.  The  proper  plan,  it  seems  to  me,  is  to  hold  it  in 
reserve  for  cases  which  defy  other  therapeutic  measures,  aud,  when 
these  arise,  to  employ  it  in  combination  with  them.  From  corre- 
spondence with  several  of  our  best  physicians,  as  well  as  from  read- 
ing our  current  medical  literature,  I  am  convinced  that  we  cannot 
afford  to  ignore  it  as  a  means  of  salvation,  in  occasional  cases. 

Saveral  reliable  brands  of  horse-serum  are  in  the  market,  each 
package  being  accompanied  by  full  directions.  Where  death  has 
seemed  imminent  in  a  few  hours,  numerous  cases  of  malignant  diph- 
theria have  convalesced  within  twenty-four  hours  after  the  hypo- 
dermic use  of  this  agent;  the  temperature  speedily  falls,  the  mem- 
brane rapidly  disappears,  the  symptoms  of  prostration  pass  away, 
and,  though  an  erythematous  rash,  with  cutaneous  irritation,  may 
attend,  convalescence  soon  follows.  However,  it  should  only  be 
employed  in  those  cases  which  offer  little  other  hope. 


ERYSIPELAS.  187 

XVI.   EEYSIPELAS. 

Synonyms. — St.  Anthony's  Fire ;  Bose. 

Definition. — An  acute,  contagious  disease,  excited  by  the  strep- 
tococcus erysipelatis,  characterized  by  a  peculiar  inflammation  of 
the  skin  and  subcutaneous  tissue,  attended  by  an  irregular  fever  and 
tendency  to  rapid  spread,  with  speedy  resolution  and  liability  to 
relapse. 

Etiology. — The  cause  of  this  is  undoubtedly  local  infection 
from  a  specific  germ,  which  gains  entrance  to  the  tissues  through 
some  abrasion  of  the  cutaneous  or  mucous  surface.  The  disease 
was  formerly  divided  into  traumatic  and  idiopathic  erysipelas,  from 
the  fact  that  it  develops  occasionally  in  wounds,  and  seems  to  some- 
times develop  upon  a  cutaneous  surface  where  no  abrasion  of  the 
skin  has  been  made;  but  closer  inspection  will  always  show  that 
there  has  been  an  opening  in  the  integument,  through  which  the 
germ  has  entered.  The  division,  therefore,  is  manifestly  illogical. 
The  abrasion  may  amount  to  only  a  slight  excoriation,  such  as  a 
mosquito  bite,  a  small  pustule,  an  intertrigo,  or  some  minute  point 
that  escapes  notice  until  the  erysipelatous  manifestation  is  developed. 
A  common  place  for  the  appearance  of  the  disease  is  the  face,  and 
the  first  point  of  localization  may  be  out  of  sight,  upon  the  mucous 
membrane  of  the  nose,  mouth,  eyelid,  or  ear,  it  spreading  from  there 
upon  the  skin,  through  one  of  the  natural  orifices.  Or,  it  may  arise 
at  the  genitals  or  anus,  intertrigo,  eczema,  chafing,  a  pustule,  an  ulcer, 
or  some  other  break  in  the  skin,  admitting  the  infection.  Erysipelas 
may  arise  in  the  pharynx  and  traverse  the  eustachian  tube  to  the 
middle  ear,  pass  through  the  tympanum  and  appear  on  the  face;  or  it 
may  arise  in  the  nose,  and  passing  through  the  nasal  duct,  appear  in 
the  eye,  to  spread  from  there  to  the  face;  or  it  may  pass  from  the  nos- 
tril to  the  face,  or  from  the  pharynx  through  the  mouth,  and  the  dis- 
ease seem  idiopathic,  when  some  abrasion,  not  observable,  has 
allowed  the  streptococci  to  enter  the  tissues.  Erysipelas  is  pecul- 
iarly severe  and  fatal  in  new-born  children,  though  after  six  months 
of  age  it  is  not  more  severe,  probably,  than  in  adults.  Puerperal 
women  are  also  more  than  ordinarily  susceptible  to  the  infection. 
Vaccination  provides  a  ready  point  for  the  entrance  of  the  infection, 
and  erysipelas  is  not  an  uncommon  sequela  of  that  operation.  That 
the  disease  can  be  communicated  from  one  to  another,  has  been 
proven  by  the  vaccination  of  several  persons  from  one  who  shortly 
afterward  developed  it,  all  the  others  soon  developing  the  disease 
also.  This  is  one  of  the  principal  objections  to  the  employment  of 
humanized  virus  in  vaccination.  Some  persons  seem  predisposed  to 
yearly  attacks  of  erysipelas,  the  disease  returning  about  the  same 


188  SPECIFIC  INFECTIOUS  DISEASES. 

period,  for  years  in  succession.  The  face  is  usually  the  point  of 
attack  here,  rhinitis,  eczema,  acne,  or  some  other  abrasion  of  the 
skin  affording  it  entrance.  Erysipelas  usually  occurs  sporadically, 
though  epidemics  occasionally  develop. 

It  has  been  a  disputed 
question  whether  the  germ  of 
erysipelas  is  a  separate  and 
distinct  organism,  similar  to 
but  not  identical  with  the 
pus-streptococcus.  Koch  and 
others,  after  careful  investi- 
gation, have  decided  that  it 
is  identical  with  the  s'repto- 

-| 

•««.%.(*•»*«•  curt*.)       COGC.US  pyogenes,  while  others, 
probably    fully   as    reliable, 

declare  that  though  the  similarity  is  great,  there  is  a  distinction. 
From  a  clinical  standpoint,  the  latter  view  seems  the  correct  one. 

Pathology. — An  early  infiltration  of  the  skin  and  subcutaneous 
connective  tissue  is  the  first  marked  pathological  alteration,  though 
careful  inspection  will  now  find  the  streptococci  occupying  the  lym- 
phatics, where  they  are  at  first  confined,  whence  they  soon  afterward 
invade  the  adjacent  connective  tissue.  The  skin  becomes  cedema- 
tous  and  sharply  raised  over  the  affected  area,  the  part  being  at 
first  bright-red,  tense,  and  shining,  though  afterward  becoming  livid 
or  brown,  the  epidermis  now  being  thrown  off  in  scales  or  flakes. 
The  infiltration  is  serous  or  fibrinous  in  character,  and  contains  an 
abundant  supply  of  cells  (leucocytes),  which  surrouud  the  vessels. 
The  streptococci,  which  first  appear  in  the  lymphatics,  soon  invade 
the  connective  tissue  of  the  skin,  and,  sparingly,  the  subcutaneous 
tissues,  in  chaplets  or  coherent  masses,  which  constitute  colonies, 
and  around  which  necrotic  changes,  more  or  less  marked,  occur.  The 
amount  of  exudation  and  necrotic  change  determines  the  severity 
and  characteristics  of  the  case.  Where  the  exudation  is  moderate 
in  amount,  there  is  not  very  extensive  destruction  of  tissue,  scaling 
and  flaking  of  the  epidermis,  with  a  more  or  less  permanently  estab- 
lished debility  of  the  skin  being  left  behind,  manifested  by  a  deep- 
ening of  the  color  of  the  affected  part,  which  may  persist  for  some 
time  after  convalescence.  Where  the  exudation  is  more  abundant, 
blebs  and  vesicles  rise  on  the  surface,  due  to  necrotic  changes  in  the 
cells  of  the  rete  Malpighii,  at  numerous  adjacent  points,  with  subse- 
quent deliquescence  of  the  partitions,  and  liquefaction  of  the  con- 
tents. This  constitutes  erysipelas  vesiculosuin  or  bullosum.  Some- 
times pus  accumulates  instead,  constituting  erysipelas  pustulosttm. 


EKYSIPELAS.  189 

These  dry  up  into  scabs,  becoming  erysipelas  crustosum,  and  if  necro- 
sis occur  about  them,  we  have  erysipelas  gangrenosum,  the  necrosis 
varying  in  extent  markedly,  in  various  cases.  The  mucous  membrane 
of  the  respiratory  tract  may  partake  of  the  general  characteristics  of 
the  cutaneous  affection,  the  tissues  of  the  lungs  becoming  infiltrated 
and  occupied  by  streptococci,  with  the  resultant  changes.  The 
pathological  condition  will  differ  from  croupous  pneumonia,  from  the 
fact  that  there  is  no  plastic  exudation  into  the  alveoli,  as  in  that  dis- 
ease. In  severe  and  prolonged  cases,  the  tissues  generally  undergo 
the  general  changes  common  to  prolonged  pyrexia.  There  is  paren- 
chymatous  degeneration  of  tne  muscles,  intestines,  liver,  spleen,  kid- 
neys, etc.,  though  these  changes  are  not  pathognomonic  of  the  ery- 
sipelatous  disease. 

Symptoms. — From  three  to  seven  days'  incubation  occur  after 
the  entrance  of  the  streptococci,  before  the  disease  becomes  fully 
developed. 

Like  some  other  infectious  diseases,  the  actual  attack  is  preceded 
by  more  or  less  marked  prodromal  symptoms,  such  as  drowsiness, 
irritability,  malaise,  muscular  pains,  etc.  The  disease  proper  often 
begins  with  a  chill,  more  or  less  marked,  though  in  young  children, 
convulsions  or  vomiting  may  replace  it.  A  rise  of  temperature  fol- 
lows, the  thermometer  soon  marking  as  high  as  105°  F.  While 
irregular,  the  temperature  is  liable  to  remit  slightly  in  the  morning, 
with  an  evening  exacerbation,  though  this  rule  may  be  reversed.  It 
may  not  rise  above  103°  in  mild  cases,  and  it  may  reach  106°  and 
higher,  in  severe  ones,  the  temperature  depending  much  on  the  extent 
of  the  local  disease.  As  long  as  the  local  inflammation  continues  to 
advance,  the  fever  continues  high,  though  the  advance  usually  ceases 
by  the  third  or  fourth  day.  About  the  fifth  or  sixth  day  it  may  fall 
rapidly  to  normal,  though  this  cannot  be  depended  upon.  With 
rise  of  temperature,  the  pulse  becomes  correspondingly  increased  in 
rapidity,  ranging,  in  adults,  from  100  to  120  per  minute. 

The  local  manifestation  is  almost  always  a  coincidence ;  an  elevated, 
reddened  point  of  localization  is  observed,  which  spreads  rapidly, 
showing  an  abrupt  elevation  at  its  borders,  and  in  which  there  are 
sensations  of  tension,  burning,  itching,  tingling,  and  darting  pains. 
The  redness  disappears  upon  pressure,  leaving  a  pit  in  the  cedema- 
tous  tissue,  but  returns  rapidly  upon  its  removal,  the  part  being 
sensitive  to  touch.  Where  the  subcutaneous  tissue  is  abundant,  as 
about  the  eyes,  the  swelling  is  a  remarkable  feature  of  the  disease, 
the  eyes  soon  being  swollen  shut,  their  presence  almost  obliterated, 
and  the  countenance  disfigured.  During  the  active  progress  of  the 
disease,  while  the  fever  remains  high,  it  is  accompanied,  in  many 


190  SPECIFIC  INFECTIOUS  DISEASES. 

cases,  by  severe  constitutional  symptoms,  such  as  loss  of  appetite, 
nausea,  vomiting,  intense  headache,  thirst,  and  even  delirium.  The 
tongue  becomes  dry  and  brown,  and  is  usually  covered  with  a  thick 
coating,  which  may  be  pasty-white.  The  urineia  scanty,  high  colored, 
and  often  albuminous,  and  the  botoels  are  constipated.  Where  the 
face  and  scalp  are  extensively  affected,  the  patient  may  be  delirious 
or  comatose.  Where  the  mucous  membranes  join  the  skin  near  the 
point  of  attack,  they  are  frequently  involved.  When  recovery  termi- 
nates the  case,  the  swelling  gradually  subsides,  the  redness  disap- 
pears, the  temperature  declines,  secretion  becomes  reestablished, 
and  the  appetite  returns.  Where  death  ensues,  the  patient  usually 
dies  with  a  high  temperature. 

The  disease  manifests  a  marked  predilection  for  the  face  and 
scalp,  it  being  estimated  that  nearly  seventy  per  cent  of  the  cases 
encountered  are  located  here.  Where  the  scalp  is  deeply  involved, 
a  permanent,  or  at  least  a  long-continued,  alopoecia  may  result  over 
the  most  severely  affected  surface. 

In  the  new-born,  the  disease  usually  commences  about  the  navel 
or  the  genitals.  Imperfect  healing  of  the  navel  may  leave  an  open- 
ing for  the  entrance  of  the  miroorganisms,  and  chafing  about  the  pri- 
vates, so  common  in  very  young  children,  is  attended  by  excoriations, 
offering  abrasions  favorable  for  the  ingress  of  the  disease.  The  dis- 
ease arises  insidiously  in  these  cases  usually,  only  a  slight  blush 
indicating  its  presence,  for  three  or  four  days.  Finally,  a  high  fever 
develops,  and  the  local  manifestation  becomes  observable.  The  skin 
is  soon  enormously  distended  and  glistening,  subcutaneous  abscesses 
develop  in  many  cases,  and  gangrene  soon  follows.  The  inflamma- 
tion iray  extend  along  the  umbilical  vein,  and  paritonitis,  with  puru- 
lent infiltration,  result.  The  child  is  extremely  restless,  cries  con- 
stantly, refuses  nourishment,  finally  becomes  comatose,  and  dies  in 
this  condition,  or  in  convulsions. 

The  disease  is  an  acute  one,  and  runs  its  course  in  from  ten  to 
fourteen  days,  usually,  though  it  may  leave  serious  sequelae,  which 
may  persist  for  a  long  time.  Among  these  are  abscesses  of  the  skin, 
gangrene,  bronchitis,  and  pneumonia.  Where  the  throat  is  severely 
involved,  oedema  of  the  glottis  may  arise.  Cardiac  affections,  such 
as  endocarditis  and  pericarditis,  may  ensue.  Inflammation  of  the 
meninges  sometimes  results,  and  death  may  be  caused  by  this  affec- 
tion, the  disease  extending  through  some  of  the  foramina,  where  the 
head  and  face  are  involved.  Eye  affections,  such  as  keratitis,  pan- 
ophthalmitis,  and  amaurosis,  are  of  occasional  occurrence. 

Diagnosis. — The  diagnosis  of  erysipelas  is  not  difficult.  The 
intense  redness  and  swelling,  localized,  and  usually  known  to  arise 


ERYSIPELAS.  191 

from  a  wound  or  break  in  the  integument,  the  intense  swelling,  with 
abrupt  border  of  the  tumefaction,  this  being  accompanied  with  high 
fever  and  other  marked  constitutional  symptoms,  can  hardly  be  mis- 
taken for  any  other  disease.  Rims  poisoning  might  present  some  of 
the  local  symptoms  of  erysipelas,  but  the  severe  constitutional  symp- 
toms would  be  absent.  Other  cutaneous  affections  would  be  subject 
to  the  same  exception.  Where  there  was  any  question  in  the  clini- 
cal aspect,  a  microscopical  examination  might  detect  the  characteris- 
tic streptococcus. 

Prognosis. — The  character  of  the  surroundings  will  suggest 
much,  as  to  the  probable  outcome  of  a  case.  In  traumatic  ery- 
sipelas, occurring  in  crowded  hospital  wards,  the  condition  is  always 
a  serious  one.  Where  the  case  is  sporadic,  and  sanitary  conditions 
are  favorable,  with  a  patient  of  constitutional  vigor,  the  prognosis  is 
not  unfavorable.  When  the  disease  occurs  in  new-born  children  or 
puerperal  women,  a  guarded  prognosis  is  safest  for  the  reputation 
of  the  attending  physician. 

Treatment. — A  better  knowledge  of  the  etiology  and  pathology 
of  erysipelas  has  not  advanced  the  treatment  of  the  disease,  to  any 
great  extent.  The  best  treatment  we  possess  is  an  empirical  one, 
though  the  general  principles  of  dynamical  therapeutics  apply  here, 
as  elsewhere.  The  treatment  may  be  divided  into  constitutional  and 
local,  the  aim  being  to  neutralize  the  ptomaines  generated  and  the 
inflammatory  action  as  much  as  possible,  it  not  being  probable  that 
treatment  directed  to  the  destruction  of  the  streptococci  will  amount 
to  anything  more  than  an  aggravation. 

It  is  well  in  the  beginning  of  treatment  to  inspect  the  tongue 
carefully,  to  see  if  there  be  any  prominent  indication  of  blood-sepsis. 
One  of  two  remedies  will  be  indicated  here,  provided  there  is  any 
call  for  remedies  of  this  character.  We  may  have  the  sulphite  of 
sodium  indication,  suggested  by  the  broad,  flabby  tongue,  with  pallid 
mucous  membrane,  covered  with  the  pasty- white  coating;  and  we 
may  have  the  sulphurous  acid  tongue,  indicated  by  the  dark-red  mucous 
membrane  with  brown  coating,  this  being  usually  dry.  Sometimes 
there  is  no  prominent  tongue  indication,  and  the  treatment  is  much 
simplified.  For  the  sodium  tongue,  we  will  administer  capsules  con- 
taining sodium  sulphite,  1  gr.,  every  three  hours.  For  the  sulphu- 
rous acid  tongue,  twenty  drops  of  this  drug,  well  diluted,  at  about 
the  same  intervals. 

Having  seen  to  it  that  provision  is  made  for  sepsis  as  indicated 
by  the  tongue,  we  will  devote  ourselves  to  other  treatment,  nearly  if 
not  quite  as  important.  The  nature  of  erysipelas  is  to  destroy  con- 
nective tissue  by  necrosis.  If  we  can  mitigate  this  tendency,  we  shall 


192  SPECIFIC  INFECTIOUS  DISEASES. 

be  able  to  modify  the  extent  of  the  destructive  action,  lessen  the 
spread  of  the  disease,  and  protect  the  tissues  from  very  severe  inflam- 
matory and  degenerative  changes,  as  well  as  ameliorate,  considerably, 
the  severity  of  the  general  symptoms.  Our  best  remedy  for  necrosis 
of  soft  tissues  is  echinacea;  and  it  should  constitute  a  portion  of  the 
treatment  of  every  case,  being  administered  steadily  throughout  the 
entire  course  of  the  disease.  It  is  not  incompatible  with  any  other 
remedy  we  may  need,  and  can  be  administered  in  combination  (in 
alternation,  or  in  conjunction)  with  any  other  treatment.  Ten  or  fif- 
teen drops  may  be  advantageously  administered,  to  an  adult,  every 
hour  during  the  height  of  the  disease,  and  four  or  five  times  a  day 
during  convalescence,  to  guard  against  relapse. 

A  high  temperature  would  suggest  the  combination  of  jdborandi 
with  echinacea,  three  or  four  drops  of  the  specific  medicine  every 
hour  tending  to  reduce  the  temperature  as  well  as  the  local  inflam- 
mation, through  its  sedative  action.  Any  one  who  has  experienced 
the  gratefully  cooling  influence  upon  the  skin  in  his  own  person  dur- 
ing fever  or  inflammatory  action,  can  appreciate  the  benefit  liable  to 
be  derived  from  this  remedy  in  such  a  condition  as  erysipelas. 

E/ius  tox.  is  especially  useful  as  a  sedative  where  the  tissues  of 
the  face  are  involved,  as  it  seems  to  possess  a  specific  influence  upon 
this  part,  and  exerts  its  influence  for  the  better  speedily  and  effec- 
tively. I  employ  it  in  combination  with  aconite,  using  five  or  eight 
drops  of  specific  aconite  to  fifteen  or  twenty  of  rhus,  in  half  a  glass 
of  water,  giving  a  teaspoonful  every  hour.  Where  the  tongue  is  red- 
dened at  the  tip  and  edges,  and  pointed,  tremulous  on  protrusion,  or 
where  the  patient  is  particularly  restless,  or  nauseated,  it  is  espe- 
cially commendable. 

Markedly  necrotic  conditions  might  suggest  the  use  of  baptisia, 
though  it  would  be  difficult  to  imagine  a  case  where  baptisia  would 
succeed  if  echinacea  had  failed  to  arrest  the  tendency  to  gangrene. 
LacJiesis  should  be  borne  in  mind  where  phagedenic  tendencies  are 
pronounced,  two  or  three  grains  of  the  6x  or  lOx,  every  two  hours. 

Periodicity  might  be  present  in  a  malarious  region,  and  demand 
the  use  of  an  antiperiodic.  In  such  a  case,  the  antiperiodio  would 
constitute  an  important  part  of  the  treatment,  and  it  should  be  used 
appropriately,  the  exacerbation  being  anticipated  with  proper  doses 
of  yuinia  sulphas  for  several  days,  until  the  periodicity  has  been 
interrupted.  In  treating  children  and  delicate  persons,  the  3x  trit- 
uration  of  arseniate  of  quinia  may  be  found  more  acceptable  to  the 
stomach,  less  disagreeable  to  the  nerves,  and  fully  as  effective,  given 
in  two-  or  three-grain  doses,  four  or  five  times  daily. 

Local  applications  should  figure  extensively,  in  the  treatment  of 


SEPTICAEMIA  AND  PYAEMIA.  193 

erysipelas.  Echinacea  is  one  of  the  best  of  these,  its  antagonism  to 
necrosis  of  tissue  being  as  well  marked  locally  as  constitutionally. 
Cloths  saturated  in  a  twenty-five  per  cent  dilution  of  a  saturated 
tincture  or  the  specific  medicine,  in  water,  should  be  laid  upon  the 
affected  area,  and  renewed  every  hour.  Acetate  of  lead  is  an  applica- 
tion which  is  soothing  and  cooling,  and  was  once  a  favorite  local  rem- 
edy with  me.  A  saturated  solution,  in  water,  may  be  applied  on  sat- 
urated cloths,  frequently  repeated.  Another  excellent  agent  is  citric 
acid,  used  in  saturated  aqueous  solution,  as  above  directed.  Another 
remedy,  which  many  laud  very  enthusiastically,  is  the  spirit  of  Min- 
dererus.  This  is  probably  the  best  use  this  old  formula  can  be  made 
of,  as  its  local  influence  in  erysipelas  is  sometimes  remarkably  fine. 

Cathartics  can  exert  no  beneficial  effect  in  the  treatment  of  this 
disease,  and  should  be  avoided,  as  their  use  is  unscientific  and 
uncalled  for.  Enemata  may  be  employed  where  evacuation  of  the 
bowels  is  an  urgent  matter,  though  the  small  amount  of  food  con- 
sumed will  obviate  necessity  that  the  bowels  move  every  day. 

Complications  should  be  met  by  rational  measures.  Abscesses 
should  be  opened  early,  and  cleansed  with  dilute  peroxide  of  hydro- 
gen, diluted  echinacea,  or  weak  solutions  of  carbolic  acid  and  glycer- 
ine, in  water.  Ophthalmic  complications  will  call  for  the  local  appli- 
cation of  diluted  echinacea,  a  weak  solution  of  citric  acid  or  sugar  of 
lead.  Cardiac  complications  may  demand  calcium  fluoride,  cactus 
grandiflorus,  or  convallaria. 

The  diet  should  be  nutritious  but  not  stimulating,  fatty  meats 
and  high  seasoning  being  forbidden.  Milk,  plain  and  malted,  fari- 
naceous foods,  digestible  fruits  and  vegetables,  and  eggs,  well  cooked 
or  rare,  will  constitute  an  appropriate  regimen. 

XVIL   SEPTIOEMIA  AND  PYJEMIA. 

SEPTIOJSMIA  and  pysemia  are  often  confounded.  Some  medical 
writers  have  even  failed  to  distinguish  between  them,  but  have 
regarded  the  two  conditions  as  identical.  However,  there  is  at  least 
one  distinguishing  feature,  and  that  is  that  pyaemia  is  marked  by  the 
diffusion  of  abscesses  through  various  parts  of  the  body,  as  the  result 
of  lodgment  of  ernboli  distributed  from  a  primary  abscess,  while 
septicaemia  is  a  general  poisoning  of  the  fluids,  without  foci  of  sup- 
puration. Each  will  be  considered  separately. 

SEPTICAEMIA. 

Definition. — A  general  febrile  disease,  without  foci  of  suppu- 
ration, caused  by  the  absorption  of  septic  bacteria  and  their  pto- 
maines— usually  bacteria  of  suppuration. 

14 


194  SPECIFIC  INFECTIOUS  DISEASES. 

Etiology. — Septicaemia  may  result  either  from  the  absorption 
of  toxines  from  without  the  circulation  (septic  intoxication),  or  from 
the  generation  of  toxines  in  the  circulation,  through  the  multiplica- 
tion of  septic  bacteria  within  the  blood-vessels  (septic infection).  In 
either  case,  absorption  of  septic  material  or  bacteria  must  first  take 
place  from  some  nidus  of  putrefaction  in  intimate  association  with 
the  circulation,  such  as  ft  pent-up  wound,  a  retained  placenta  under- 
going decomposition,  typhoid  ulcers,  old  tubercular  cavities,  etc., 
from  which  free  access  of  air  is  excluded.  Cavities  open  to  the  air 
hardly  ever  become  the  origin  of  septicaemia. 

Symptoms. — There  is  great  variation  in  the  severity  of  the 
symptoms  of  different  cases  of  septicaemia,  depending  upon  the 
amount  and  intensity  of  the  septic  material  giving  rise  to  them. 
Some  cases  may  be  so  mild  as  to  be  almost  overlooked,  while  others 
are  so  profound  as  to  result  fatally,  within  one  or  two  days  after  the 
onset. 

Senn,  in  his  Principles  of  Surgery,  segregates  cases  of  septicaemia 
into  three  general  classes:  namely,  (1)  fermentative  fever,  (2)  sap- 
rsemia,  and  (3)  progressive  septicaemia. 

Fermentative  fever  (resorption  fever)  is  the  simplest  form  of 
wound  complications,  the  absorption  of  mildly  septic  fluids  being 
similar  in  results  to  those  of  transfusion,  or  the  injection  of  pepsin 
into  the  blood.  It  may  follow  slight  injury  or  operation,  especially 
operations  where  superficial  necrosis  in  wounds  attends  the  action 
of  solutions  used  in  dressings;  or  it  may  result  from  extravasation 
of  blood.  Soon  after  the  development  of  the  provoking  cause — 
within  a  few  hours — a  mild  fever  (without  a  chill)  arises,  the  tem- 
perature rapidly  running  up  to  103°  or  104°  F.,  where  it  may  remain 
for  twenty-four  or  seventy-two  hours,  when  it  subsides  spontaneously, 
no  severe  constitutional  symptoms  appearing  at  any  time. 

Saprcemia  is  a  form  of  septic  intoxication  due  to  putrefactive 
changes  occurring  in  dead  material.  Ptomaines  are  thus  formed, 
various  microorganisms  being  concerned  at  divers  times,  such  as 
pyogenic  bacteria,  and  various  forms  of  the  proteus  group.  As  these 
microbes  multiply  and  grow,  toxines  are  developed,  which  are 
absorbed  into  the  circulation,  and  produce  the  condition  just  named. 
SapraBmia,  then,  is  the  toxaemia  resulting  from  the  introduction  of 
ptomaines  into  the  blood  from  a  putrefactive  localized  focus.  Soon 
after  the  absorption  of  such  material,  constitutional  symptoms 
develop;  a  slight  chill  is  followed  by  marked  reaction,  the  tempera- 
ture rising  to  103°  or  104°  F.,  with  rapid  pulse,  headache,  perhaps 
nausea  and  vomiting,  and  great  prostration.  Typhoid  symptoms 
rapidly  follow,  there  being  restlessness  and  delirium,  with  reddened, 


SEPTICAEMIA  AND  PY.2EMIA.  195 

pointed  tongue,  which  later  becomes  dry  and  contracted,  or  presents 
a  glazed  appearance.  Three  factors  are  necessary  to  produce  this 
condition:  namely,  dead  tissue,  putrefactive  infection  of  this  mate- 
rial with  septic  microorganisms,  and  time  for  the  ptomaines  to  be 
absorbed.  A  focus  of  putrefaction  may  be  due  to  lacerated  or  bruised 
tissues,  blood-clots  in  wounds,  to  retained  secundines,  etc. 

Progressive  septicaemia  is  due  to  more  than  absorption  from  a 
localized  focus  of  putrefaction.  In  addition  to  ptomaines  absorbed, 
microorganisms  within  the  blood  continue  to  generate  toxinos.  The 
microbes  most  common  in  this  form  of  septicaemia  are  the  pyogenic 
bacteria. 

The  symptoms  of  progressive  septicaemia  are  developed  soon  after 
the  absorption  of  the  septic  material;  seldom  later  than  the  third 
day,  and  often  within  twenty-four  hours.  They  resemble  those  of 
sapraBmia,  only  they  are  more  profound.  There  is  an  initiatory  chill, 
followed  by  a  temperature  of  103°  or  104°F.,  with  varying  intermis- 
sions. The  pulse  is  weak  and  wiry  from  the  start,  evidencing  great 
prostration,  and  it  soon  becomes  soft  and  compressible.  Inflamma- 
tory action  may  proceed  rapidly  along  the  lymphatics,  from  the  focua 
of  putrefaction  to  vital  organs.  The  patient  inclines  to  drowsiness 
and  stupor,  early,  though  he  may  be  aroused  by  violent  vomiting 
alternated  with  diarrhoea.  The  face  presents  a  yellowish  pallor,  and 
assumes  a  vacant  expression ;  the  pupils  are  often  dilated,  and  the 
tongue  is  dry,  and  red  at  the  edges,  with  a  brown  dorsum.  Such 
cases  are  liable  to  prove  fatal  within  from  two  to  four  days. 

Diagnosis. — The  difference  between  the  symptoms  of  this  dis- 
ease and  pyaemia  is  sufficiently  characteristic  to  enable  the  practi- 
tioner to  readily  differentiate.  In  septicaemia  there  is  not  the  pro- 
nounced chill  at  the  initiation  that  marks  pyaemia,  which  is  ushered 
in  by  a  pronouuced  rigor.  In  pyaemia  the  chills  recur,  and  are  as 
prominent  as  an  ague,  in  some  cases,  while  in  septicaemia  there  is 
but  the  one  chilly  period,  and  that  is  at  the  onset,  and  it  usually 
amounts  to  only  slight  shivering,  or  mild  rigors.  In  septicaemia  the 
temperature  rises  rapidly  to  105°  or  107°  F.,  while  in  pyaemia  it 
gradually  rises  to  102°  or  104°.  The  skin,  in  pyaemia,  presents  & 
peculiar  leaden  yellow  hue,  while  in  septicaemia  there  is  not  this 
peculiar  discoloration.  Pyaemia  develops  gradually,  while  septicae- 
mia is  a  disease  of  rapid  onset.  The  history  of  the  case  will  usu- 
ally assist  in  determining  between  septicaemia  and  typhus  or  typhoid 
fever,  should  there  be  any  question  in  this  direction. 

Prognosis. — The  prognosis  will  depend  upon  the  amount  of 
septic  material  absorbed  in  the  beginning,  and  upon  the  facility  with 
which  the  putrefactive  focus  can  be  evacuated,  and  rendered  aseptic. 


196  SPECIFIC  INFECTIOUS  DISEASES. 

Where  the  symptoms  are  mild  in  the  beginning  and  it  is  possible  to 
evacuate  the  offending  material,  as  by  cleansing  the  uterus,  when  it 
contains  putrefactive  placental  remains,  with  proper  curettage,  there 
is  good  ground  for  a  favorable  prognosis.  But,  when  the  onset  is 
violent,  the  patient  being  immediately  seized  with  urgent  vomiting 
and  purging,  delirium  speedily  following,  there  is  but  little  pros- 
pect that  recovery  will  follow.  Collapse  and  dissolution  are  liable 
to  soon  attend  such  a  condition. 

Treatment. — The  treatment  of  severe  cases  of  septicaemia  will 
be  more  of  a  surgical  than  therapeutic  nature.  Septic  cavities 
should  be  drained  and  cleansed  with  antiseptic  solutions  as  thor- 
oughly as  possible,  at  an  early  date.  If  the  uterus  contain  putrefac- 
tive material,  it  should  be  evacuated  by  proper  curettage  and  flushed 
frequently,  with  warm  antiseptic  solutions,  until  constitutional  symp- 
toms have  passed  away.  In  puerperal  peritonitis,  where  the  perito- 
neal sac  contains  septic  material,  the  only  probable  chance  for  the 
life  of  the  patient  is  a  thorough  cleansing  of  the  cavity  with  anti- 
septics, through  an  abdominal  incision.  All  putrefactive  cavities 
should  be  repeatedly  flushed,  until  dead  material  has  been  completely 
removed.  Therapeutic  measures  may  accomplish  some  good.  Tongue 
indications  should  be  carefully  observed,  and  any  prominently  indi- 
cated dynamical  antiseptic  administered,  as  soon  as  called  for.  Sul- 
phite of  sodium  or  sulphurous  acid  may  be  required,  though  baptisia 
or  echinacea  may  often  serve  a  good  purpose.  Professor  Scudder's 
favorite  remedy  for  septicaemia  due  to  putrefying  placental  material, 
when  there  was  fetor  about  the  patient,  was  minute  doses  of  potas- 
sium chlorate.  To  counteract  the  prostration,  heart  stimulants,  such 
as  nitro-g^cerine  or  strychnia  (hypodermically),  may  be  demanded  to 
tide  the  patient  over.  Restlessness  and  delirium,  with  pyrexia,  may 
call  for  aconite  and  rhus  tox.,  gelsemium,  OTjaborandi. 

Lachesis,  in  2-grain  doses  of  the  6x  trituration,  repeated  every 
two  hours,  is  an  excellent  internal  remedy  to  correct  the  septic  con- 
dition of  the  blood. 

Prophylaxis  consists  in  observing  proper  antiseptic  precautions 
in  the  management  of  wounds,  abortions,  and  obstetrical  cases. 

PY2EMLL 

Synonym. — Pyothremia. 

Definition. — A  general  infectious  febrile  disease,  resulting  from 
the  entrance  of  emboli  infected  with  the  microbes  of  suppuration 
into  the  circulation,  characterized  by  the  formation  of  metastatio 
abscesses  in  various  parts. 

Etiology. — The  cause  of  pyaemia  was  once  believed  to  be  the 


SEPTIC^MIA  AND  PYAEMIA.  197 

absorption  of  pus  into  the  circulation  from  primary  suppurating  sur- 
faces. Later,  Virchow  called  attention  to  the  part  played  in  the 
genesis  of  the  metastatic  abscesses  by  thrombi  and  emboli,  and  later 
investigators  now  declare  that  these  emboli  must  be  charged  with 
pyogenic  microbes  (infected),  in  order  that  infarctions  shall  degen- 
er.ite  into  embolic  abscesses.  The  results  of  lodgment  of  non-infec- 
tious material  (emboli)  are  simply  mechanical — infarctions — but  when 
a  thrombus  contains  pyogenic  bacteria,  the  leucocytes  and  embryonic 
cells  degenerate  into  pus-corpuscles,  and  a  focus  of  suppuration 
results.  When  pus-organisms  induce  coagulation  necrosis  in  the 
smaller  vessels  about  suppurating  wounds,  producing  thrombi  and 
purulent  phlebitis,  small  fragments  of  the  thrombi  (emboli)  are  car- 
ried by  the  circulation  to  different  parts,  where  they  find  lodgment, 
the  pus  microbes  there  forming  colonies,  and  setting  up  suppuration. 

Pathology. — The  distribution  of  metastatic  abscesses  depends 
upon  the  location  of  the  primary  distributing  focus — on  its  relation 
to  the  special  portion  of  the  circulation  involved. 

In  external  wounds  and  osteo-myelitis,  as  well  as  in  acute  cuta- 
neous phlegmon,  the  embolic  abscesses  are  most  liable  to  develop 
wedge-shaped  infarcts  in  the  lungs ;  though  the  emboli  may  pass 
through  these  organs,  and  become  lodged  in  the  liver  or  kidneys. 

"When  the  primary  suppurative  foci  are  in  the  first  capillary  dis- 
tribution of  the  portal  circulation,  as  in  the  intestines  in  typhoid 
fever,  the  metastatic  abscesses  appear  in  the  substance  of  the  liver, 
with  or  without  pyelo-phlebitis. 

Ulcerative  endocarditis  may  result  in  showers  of  small  metastatic 
abscesses  which  invade  the  lungs  when  the  right  endocardium  is 
involved,  and  the  spleen,  kidneys,  intestines,  and  skin,  when  the 
suppurative  action  is  in  the  left  heart  (the  arterial  pyaemia  of 
Wilks). 

So-called  idiopathic  pyaemia  occurs,  in  which  the  primary  lesion 
is  not  apparent,  but  in  which  numerous  abscesses  are  scattered 
about,  in  various  parts. 

The  blood,  in  pyaemia,  tends  to  spontaneous  coagulation  in  the 
vessels,  wherever  there  is  slowing  of  the  current.  Colonies  of 
micrococci  are  found  in  various  places  in  the  blood,  and  on  the  walls 
of  the  vessels. 

Pyrexial  changes  are  observed  in  the  internal  organs  and  other 
soft  tissues,  similar  to  the  granular  degeneration  marking  other 
febrile  diseases.  The  spleen  is  swollen,  and  exhibits  parenchyma- 
tousdegeneration. 

Pygemic  inflammation  of  the  serous  membranes  is  often  present, 
the  pleura,  peritoneum,  and  pericardium,  being  involved.  The  pleura 


198  SPECIFIC  INFECTIOUS  DISEASES. 

is  especially  susceptible,  the  plenral  cavity  sometimes  filling  rap- 
idly with  purulent  material  Snppurative  arthritis  may  occur,  and 
lymphangitis  is  liable  to  arise  in  the  neighborhood  of  metastatic 
abscesses. 

Symptoms. — Chitta  are  important  symptoms  of  pyaemia,  these 
occurring  at  the  commencement  of  the  disease,  six  or  seven  days 
after  the  infection  which  gives  rise  to  it  has  begun.  The  chills 
may  recur  regularly  or  irregularly.  When  they  recur  with  regular- 
ity, the  condition  is  liable  to  be  mistaken  for  malaria.  The  more 
frequent  the  chilis,  the  more  numerous  the  metastatic  abscesses, 
the  chilliness  usually  heralding  the  origin  of  a  new  point  of  infec- 
tion, and  attending  the  commencement  of  suppurative  action. 

The  fever  which  attends  varies  in  character,  though  it  is  usually 
intermittent  or  remittent.  When  intermittent,  the  temperature  may 
rise  to  104°  during  the  acme,  continue  there  a  few  hours,  then  sub- 
side, with  sweating,  to  normal  In  some  cases  there  may  be  several 
chills  during  twenty-four  hours,  with  paroxysms  of  fever  between, 
each  chill  being  preceded  by  a  remission,  or  the  temperature  fall- 
ing to  or  below  normal. 

Gastric  symptoms  are  not  usually  so  marked  as  in  septicaemia, 
nausea  and  vomiting  seldom  occurring;  and  delirium  is  rarely  pres- 
ent, unless  the  brain  be  the  seat  of  metastatic  abscesses,  the  men- 
tal condition  continuing  sound  throughout.  The  pulse  soon  becomes 
feeble  and  rapid,  and  the  skin  assumes  an  icteric  tint,  due,  suppos- 
ably,  to  the  destruction  of  red  corpuscles  and  consequent  staining  of 
the  skin  with  hematoidin. 

The  local  as  well  as  the  general  symptoms  vary  in  proportion  to 
the  number  and  location  of  the  abscesses.  Where  many  emboli  are 
diffused  throughout  the  body,  they  are  usually  small,  and  the  local 
symptoms  are  obscured  largely  by  the  severe  and  rapidly  fatal  gen- 
eral disturbance,  the  disease  terminating  with  typhoid  symptoms 
and  death,  in  from  one  to  three  weeks.  In  those  cases  where  the 
emboli  are  fewer,  a  more  chronic  course  follows,  and  the  active  con- 
stitutional symptoms  are  less  severe.  Such  cases  are  more  chronic, 
and  the  locations  of  the  abscesses  are  indicated  by  pain,  and  varying 
functional  disturbances. 

When  the  lungs  are  involved,  dyspnoea  will  be  a  constant  symp- 
tom, its  extent  being  determined  by  the  number  and  size  of  the 
abscesses.  Large  abscesses  located  near  the  pleura  will  give  rise  to 
pleural  inflammation,  signalized  by  lancinating  pains  and  dry  crep- 
itus,  or  friction  sounds,  upon  auscultation.  Over  the  region  of 
the  infarct  may  be  heard  crepitant  rales  and  bronchial  respira- 
tion, and  percussion  will  now  discover  dullness.  If  the  abscesses 


SEPTICAEMIA  AND  PT^MIA.  199 

be  located  near  the  heart,  the  pericardium  may  be  involved,  and 
cardiac  symptoms  supervene. 

Embolic  abscesses  in  the  kidneys  will  be  determined  by  the  pres- 
ence of  albumin  and  pus  in  the  urine.  Arthritic  abscesses  will  be 
easily  recognized  by  the  redness,  swelling,  and  pain.  Other  loca- 
tions may  be  involved  where  the  symptoms  are  obscure;  large 
abscesses  may  develop  internally,  so  insidiously — without  pain — as 
to  reach  immense  proportions  before  they  are  recognized.  In  other 
cases,  the  subcutaneous  connective  tissue  may  be  involved,  with  the 
symptoms  of  ordinary  abscess. 

Chronic  cases  may  linger  along  for  months,  before  a  final  fatal  ter- 
mination, the  patient  gradually  losing  flesh  from  the  constant  hectic, 
until  death  from  exhaustion  results,  or  extensive  amyloid  degen- 
eration of  vital  organs  interferes  with  processes  necessary  to  the 
maintenance  of  life. 

Diagnosis. — The  history  of  the  case  will  usually  assist  in 
determining  the  condition  of  affairs,  unless  there  be  idiopathic 
pyaemia  present  where  no  local  focus  of  infection  is  known.  If  mala- 
ria be  confounded  with  it,  quinine  may  be  employed  for  diagnostic 
purposes,  it  being  remembered  that  while  this  drug  will  interrupt 
the  chills  of  malaria,  it  exerts  no  pronounced  influence  over  those  of 
pyaemia.  Remembering  the  points  of  distribution  of  emboli,  we 
will  hardly  be  liable  to  confound  this  disease  with  acute  atrophy 
of  the  liver,  acute  rheumatism,  or  typhus,  or  typhoid  fever. 

Prognosis. — The  prognosis  is  always  unfavorable.  However, 
patients  of  powerful  recuperative  energies,  who  are  not  severely 
affected — where  the  abscesses  are  few  and  far  between — sometimes 
recover. 

Treatment. — It  is  doubtful  that  there  are  anti-suppurative  rem- 
edies sufficiently  potent  to  arrest  the  action  of  the  pyogenic  microbes 
after  they  have  once  entered  the  circulation  as  extensively  as  in 
pyaemia.  It  may  be  worth  while  to  attempt  this  with  echinacea,  in 
acute  cases,  and  with  calcium  sulphide  or  berberis  aquifolium  in  more 
chronic  ones;  but  the  outlook  will  not  be  very  promising.  How- 
ever, there  is  nothing  like  faith  and  perseverance,  and  these  remedies 
judiciously  administered  can  do  no  harm,  at  least.  The  anti-suppu- 
rative action  of  potassium  choride  3x  should  also  be  recollected  here. 

Abscesses,  when  accessible,  should  be  treated  antiseptically,  and 
stimulants  and  nutritives  should  be  regularly  administered,  to  sus- 
tain the  patient  as  much  as  possible. 

Allopathic  authorities  advise  the  free  use  of  alcoholic  stimulants, 
it  being  their  belief  that  life  may  thus  be  prolonged,  in  some  cases, 
until  the  disease  subsides. 


200  SPECIFIC  INFECTIOUS  DISEASES. 

XVIII.  ASIATIC  CHOLERA. 

Synonyms. — Epidemic  Cholera;  Spasmodic  Cholera;  Malig- 
nant Cholera. 

Definition. — Epidemic  cholera  is  an  acute,  specific,  infectious 
disease,  endemic  in  some  parts  of  India,  but  carried,  in  epidemic 
form,  to  other  localities.  It  manifests  itself  either  by  choleraic  diar- 
rhoea, having  no  distinct  characteristic;  cholerine,  which  differs  but 
little  clinically  from  cholera-morbus ;  and  pronounced  cholera,  char- 
acterized by  copious  "rice  water"  purging,  persistent  vomiting,  severe 
muscular  cramps,  marked  prostration,  emaciation,  and  collapse, 
rapidly  followed  by  dissolution,  or  recovery.  The  dejections  of  the 
several  varieties  contain  the  distinctive  cholera  bacillus. 

Historical  Note. — Asiatic  cholera  has  prevailed  in  India  for 
centuries,  but  until  the  great  epidemic  of  1817,  very  little  was  heard 
of  it  outside  of  the  medical  reports  of  the  East  India  Company. 
The  statement  of  some  authorities  that  cholera  originated  at  Jessore 
in  1817  is  erroneous,  as  there  were  ten  extensive  epidemics  on  the 
Indian  peninsula  from  1503  to  1817. 

The  great  cholera  epidemic  of  1817  first  attracted  general  atten- 
tion, from  the  extent  of  territory  traversed  and  the  appalling  loss  of 
life  that  followed.  Within  an  area  of  195,935  square  miles,  almost 
every  town  and  hamlet  suffered  from  its  ravages.  Europe  had  thus 
far  escaped ;  but  the  epidemic  of  1827  did  not  stop  at  the  bounda- 
ries of  India,  but,  advancing  through  Afghanistan  and  Persia,  it 
moved  on  to  Russia,  and  by  1832  it  had  devastated  the  whole  of 
continental  Europe,  aoid  had  spread  to  America.  In  1840,  during 
the  Opium  War,  the  English  troops  carried  the  disease  from  India 
to  China.  From  the  extreme  east  of  Asia  it  now  began  its  west- 
ward march,  and  traversing  the  length  of  the  continent,  entered  Rus- 
sia, in  1846.  Here,  after  decimating  the  Empire,  it  continued  its 
progress  westward,  over  Europe.  As  in  1832,  it  again  crossed  the 
Atlantic,  but  this  time  did  not  cease  its  progress  until  it  reached  the 
Pacific  Ocean,  having  traversed  the  habitable  globe  in  the  space  of 
eight  years.  In  1851-63,  cholera  again  reached  Europe  over  the  old 
route,  via  Russia,  and  passed  with  emigrants  to  this  country,  where  it 
prevailed  widely,  though  not  so  extensively  as  in  the  former  epidemic. 

The  outbreak  of  1865  chose  a  new  route.  Beginning  in  the 
Bombay  Presidency,  it  traveled  to  Mecca,  where  30,000  died  of  the 
disease.  Leaving  the  Holy  City,  it  passed  to  Alexandria,  via  Suez, 
crossed  the  Mediterranean  to  Europe,  and  reached  New  York  in  1866. 

The  last  visitation  in  this  country  occurred  in  1873,  the  disease, 
as  before,  entering  Europe  through  Russia,  and  being  brought  here 
by  European  emigrants. 


ASIATIC  CHOLERA.  201 

The  Egyptian  epidemic  occurred  in  1883,  and  was,  as  before, 
directly  traceable  to  pilgrims.  A  stringent  quarantine  prevented  its 
passing  to  Europe. 

The  last  European  epidemic  occurred  in  1892.  It  originated  in 
the  Punjab,  and  was  rapidly  disseminated  over  India.  The  great 
Twelfth  Year  pilgrimage,  with  its  million  pilgrims,  was  broken  up, 
and  flying  devotees  carried  the  plague  in  all  directions.  It  reached 
Europe  inside  of  six  months.  America  warded  it  off  by  a  rigid 
quarantine,  and,  although  New  York  harbor  was  full  of  infected  ves- 
sels, only  two  cases  occurred  on  the  mainland. 

Etiology. — The  etiology  of  cholera  has  been  a  prolific  cause  of 
controversy,  and,  although  the  doctrine  of  Koch  is  adopted  by  the 
majority  of  the  profession,  there  is  a  respectable  minority  who  reject 
(or  only  partially  accept)  his  ideas.  Numerous  theories  have  been 
advanced,  but  the  subject  is  too  extensive  to  permit  of  their  being 
discussed  here. 

Koch,  in  1884,  advanced  the  idea  that  the  disease  was  due  to  a 
specific  microbe,  the  comma  bacillus,  which  gained  entrance  to  the 
alimentary  canal  by  contaminated  food  and  water.  The  bacteria  are 

shorter  but  more  bulky  than  the  tubercle 
bacilli,  and  slightly  curved;  hence  the 
name — comma  bacillus.  Some  are  joined, 
and  form  an  S,  and,  again,  they  frequently 
grow  in  spirals.  Koch  himself  inclined  to 
the  opinion  that  they  were  a  transition 
form  between  bacilli  and  spirilli,  if  not 

.  ••11*        mi.  £          j    •       n 

genuine  spirilli.  They  are  found  in  the 
dejections,  and  in  the  structure  of  the  intestine.  Barely,  they  are 
noticed  in  the  vomitus,  but  in  that  case  regurgitation  through  the 
pylorus  is  supposed  to  account  for  their  appearance.  They  can  be 
cultivated  in  various  media,  but  drying  destroys  their  vitality.  In 
this  they  differ  from  many  other  bacteria,  notably  the  bacillus 
tuberculosis. 

Cholera  is  endemic  in  certain  localities  on  the  Indian  peninsula, 
and  within  this  district  the  disease  is  always  in  existence.  Here, 
peculiar  climatic  and  topographical  conditions,  an  overcrowded  pop- 
ulation, and  the  utter  disregard  of  sanitary  measures  among  the 
natives,  furnish  an  opportunity  for  the  development  of  microorgan- 
isms, scarcely  to  be  equaled  elsewhere.  There  have  been  no  epi- 
demics which  cannot  be  traced  back  to  the  Bombay  Presidency.  The 
disease  always  proceeds  along  the  routes  of  travel  and  commerce, 
without  regard  to  climate.  Trading  caravans,  invading  armies,  and 
pilgrim  hordes,  have  disseminated  the  disease,  time  and  again. 


202  SPECIFIC  INFECTIOUS  DISEASES. 

Cholera  is  not  contagious ;  or,  like  typhoid  fever,  only  exceptionally 
so,  and  physicians  and  nurses  handle  patients  with  impunity. 

The  bacilli  may  gain  admission  to  the  system  directly,  as  from 
food  and  water  infected  from  fecal  discharges,  or  they  may  multiply 
outside  of  the  body,  and,  contaminating  the  water  supply,  reach  the 
system  indirectly.  As  the  disease  is  propagated  from  the  stools, 
bad  sanitary  conditions  furnish  the  opportunity  for  its  spread. 
Milk,  and  vegetables  washed  in  water  containing  the  bacilli,  are  often 
sources  of  infection.  Soiled  garments  and  bed  linen  are  responsible 
for  a  great  many  cases  of  cholera.  This  has  been  noticed  frequently 
in  the  cases  of  washer- women.  In  the  East,  the  custom  of  wearing  the 
clothing  of  the  dead  is  common.  It  is,  however,  through  a  vitiated 
water  supply  that  cholera  is  principally  propagated,  and  it  is  thus 
enabled  to  disseminate  itself  through  a  community  with  astonishing 
rapidity.  The  disease  does  not  prevail  extensively  in  high  altitudes. 
Hot,  sultry  weather  is  favorable  to  its  development,  and  epidemics 
are  more  common  in  summer  and  autumn.  However,  it  may  be 
stated  that  one  of  the  worst  Russian  epidemics  occurred  during  an 
exceptionally  severe  winter.  No  age  is  exempt,  and  the  poorly  fed, 
debilitated,  and  intemperate  are  especially  prone  to  be  attacked. 

It  is  an  eastern  proverb  that  fear  kills  more  than  cholera,  but  it 
is  doubtful  if  the  emotions  have  as  much  to  do  with  rendering  the 
body  susceptible  to  the  disease  as  some  writers  imagine.  Author- 
ities differ  as  to  oue  attack  conferring  immunity  against  a  second.  If 
this  is  the  case,  the  duration  of  the  period  is  short 

Pathology. — The  post-mortem  appearances  vary  considerably, 
depending  on  the  stage  of  the  disease  in  which  death  resulted.  The 
temperature  frequently  rises  after  death,  and  the  body  cools  slowly. 
Rigor  mortis  begins  early,  and  the  rigidity  is  marked,  the  limbs 
often  being  distorted.  Post-mortem  movements  are  a  peculiar  fea- 
ture, sometimes  changing  the  position  of  the  body.  These  move- 
ments have  often  given  rise  to  reports  of  persons  being  buried  alive. 

Decomposition  is  late  in  making  its  appearance.  The  integu- 
ment has  a  leaden  pallor,  and  is  mottled  and  wrinkled.  The  blood  is 
thick,  tarry,  and  slightly  coagulable,  darker  in  color,  and  slightly 
acid.  There  is  marked  dryness  of  the  tissues.  The  peritoneum  is 
dry,  and  covered  with  a  viscid  substance.  The  stomach  presents  no 
characteristic  appearance.  The  small  intestines  usually  contain  a 
turbid,  whey-like  fluid  and  the  cholera  bacillus.  The  epithelial 
denudation  is  probably  post  mortem.  The  mucous  membrane  is 
swollen,  and  usually  pale.  The  solitary  and  Brunner's  glands,  and 
Peyer's  patches,  are  swollen  and  prominent,  the  latter  congested,  and 
occasionally  ulcerated.  The  large  intestine  is  frequently  collapsed, 


ASIATIC  CHOLEKA.  203 

and  the  solitary  and  agminated  glands  swollen.  Cases  have  occurred 
where  the  colon  appeared  normal. 

Symptoms. — The  period  of  incubation  varies  from  two  to  five 
days,  but  in  exceptional  cases  only  a  few  hours  elapse  before  the 
disease  manifests  itself. 

The  symptoms  vary  greatly  in  severity  in  different  cases,  as  is 
characteristic  of  infectious  diseases  generally.  The  degree  of  inten- 
sity does  not  necessarily  depend  on  the  number  of  bacilli  that  gain 
entrance  to  the  body,  although  this  should  usually  be  the  case.  Pre- 
disposition and  physical  conditions  have  undoubtedly  a  great  influ- 
ence in  determining  the  severity  of  the  disease.  Although  the  vari- 
eties merge  into  one  another,  there  are  three  recognized  types 
that  are  present  during  an  epidemic,  and  it  will  be  conducive  to  an 
understanding  of  the  disease  to  describe  them  separately. 

Choleric  diarrhoea  cannot  be  differentiated  from  ordinary  diarrhoea, 
except  by  bacteriological  investigation.  A  patient  may  have  what 
he  considers  a  simple  diarrhoea  and  unwittingly  communicate  the 
disease  to  others,  without  ever  knowing  that  he  has  had  Asiatic 
cholera.  All  diarrhoeas  should  therefore  be  looked  upon  with  sus- 
picion, during  an  epidemic  of  cholera.  As  a  rule,  the  flux  occurs  sud- 
denly, and  the  discharges  are  copious  and  thin.  They  range  from 
three  to  five  during  the  twenty-four  hours.  Sometimes  they  are 
more  frequent,  and  then  are  not  bile-stained.  Colic  and  griping  are 
not  usual.  There  is  a  coated  tongue,  slight  nausea,  headache,  and 
occasionally  slight  cramps  in  the  legs.  The  duration  of  the  attack 
is  from  several  days  to  two  weeks,  often  tending  to  relapse,  or  merg- 
ing into  the  more  serious  forms.  The  Koch  bacilli  are  present,  and 
can  be  demonstrated. 

In  cholerine,  there  is  vomiting  as  well  as  purging,  diarrhoea  not 
necessarily  preceding  the  former.  An  attack  resembles  cholera 
morbus  very  closely.  The  stools  are  larger  and  more  frequent  than 
in  choleraic  diarrhoea,  and  soon  become  serous,  resembling  the  rice- 
water  discharges  of  pronounced  cholera.  They  contain  the  cholera 
bacillus.  Emesis  soon  follows  the  diarrhoea,  and  after  the  contents 
of  the  stomach  are  expelled,  the  vomitus  becomes  watery  and  taste- 
less. There  may  be  considerable  thirst.  There  is  pain  in  the  epi- 
gastrium, and  abdominal  discomfort,  but  griping  is  not  necessarily 
present.  Cramping  of  the  muscles  of  the  legs  is  usually  noted.  The 
patient  complains  of  being  faint  and  dizzy.  The  urine  becomes 
scanty,  and,  if  the  purging  persists,  may  become  suppressed.  Albu- 
men is  not  unlikely  to  be  present,  in  severe  cases.  The  skin  is  cold, 
the  voice  becomes  hoarse,  and  the  features  have  an  anxious  expression. 

Some  cases  take  on  a  typhoid  condition,  with  a  slight  febrile  rise, 


204  SPECIFIC  INFECTIOUS  DISEASES. 

resulting  in  a  slow  recovery.  In  others,  the  symptoms  are  severe, 
and  collapse  comes  early  in  the  disease.  Others,  again,  develop 
pronounced  cholera,  with  all  its  characteristic  symptoms. 

Recovery  from  cholerine  is  the  rule,  though  relapses  are  frequent, 
and  convalescence  slow. 

Pronounced  Cholera. — Here,  we  recognize  three  different  stages: 
the  prodromal  stage,  the  stage  of  attack,  and  the  stage  of  reaction. 

The  prodromal  stage  varies  greatly  in  different  cases,  and  is  some- 
times not  apparent,  the  disease  beginning  with  its  more  severe  man- 
ifestations. The  period  of  incubation  varies  from  twelve  hours  to 
several  days,  and  there  is  malaise,  more  or  less  depression,  head- 
ache, restlessness,  slight  digestive  derangement,  and  a  feeling  of 
discomfort,  followed,  as  a  rule,  by  symptoms  similar  in  character  to 
those  described  under  the  head  of  choleraic  diarrhoea.  Occasionally 
there  is  no  flux  during  this  stage. 

The  diarrhoea,  if  it  has  preceded  the  period  of  attack,  becomes 
more  severe,  and  assumes  the  rice-water  appearance,  so  characteristic 
of  this  disease.  The  number  of  evacuations  increases  from  four  or 
five  to  twenty,  or,  in  some  cases,  sixty  a  day.  There  is  little  or  no 
pain  in  evacuating  the  bowel,  the  act  being  performed  without  much 
effort,  the  discharges  coming  away  in  a  stream.  Emesis  sets  in 
early,  and,  after  the  contents  of  the  stomach  are  evacuated,  the  vom- 
itus  becomes  whey-like,  resembling  the  discharges  from  the  boweU 
The  vomiting  is  projectile,  and  not  attended  with  nausea.  It  is  fre- 
quently attended  with  a  distressing  singultus.  This  excessive  loss 
of  fluid  produces  a  drying  of  the  tissues,  and  the  blood  becomes 
diminished  in  quantity,  and  thickened.  The  secretions  are  arrested, 
but  the  sweat  glands  increase  in  activity,  and  the  patient  is  covered 
with  a  clammy  perspiration.  The  cramps  in  the  muscles,  especially 
those  in  the  legs,  are  extremely  painful,  but  outside  of  this  there  is 
little  complaint 

The  patient  himself  often  expresses  surprise  at  the  little  discom- 
fort attending  the  excessive  discharges.  Sensation  is  probably 
blunted.  As  the  disease  progresses,  the  patient  emaciates  rapidly, 
the  skin  is  cold  and  dusky,  the  lips  blue,  features  pinched,  and  eyes 
sunken.  The  hands  are  wrinkled,  like  those  of  a  washer-woman,  the 
breathing  is  short  and  hurried,  increasing  to  thirty,  sometimes  forty, 
respirations  per  minute.  The  pulse  is  small  and  rapid,  at  times  dis- 
appearing from  the  wrist.  Although  the  patient's  temperature  is 
subnormal  (at  times  80°  R),  he  complains  of  heat,  and  resists  efforts 
made  to  increase  the  warmth  of  the  body.  He  is  apathetic,  and  lies 
motionless  and  indifferent,  although  conscious.  This  condition  lasts 
from  three  to  forty-eight  hours,  resulting  in  death,  or  reaction. 


ASIATIC  CHOLERA.  205 

Stage  of  Reaction. — After  passing  through  the  distressing  symp- 
toms of  the  algid  stacje,  the  patient  may  gradually  rally.  The  tem- 
perature rises,  the  pulse  and  respiration  improve,  the  cramps  cease, 
the  stools  become  infrequent  and  more  fecal,  vomiting  ceases,  the 
urine  is  secreted,  but  is  at  first  scanty,  high  colored,  and  albuminous. 
Convalescence  is  slow,  and  relapses  common. 

COMPLICATIONS. — Cholera  typhoid  is  a  common  complication  at 
this  stage,  anl  often  carries  off  the  patient  already  weakened  and 
debilitated  by  disease. 

Urcemia  is  a  serious  complication,  and  frequently  fatal.  After 
reaction,  the  urine  still  remains  suppressed  or  scanty,  and  very  albu- 
minous. The  patient  is  drowsy,  face  flashed,  pulse  slow,  and  bow- 
els constipated.  There  is  headache,  at  times  delirium.  A  spinach- 
like  material  is  vomited.  There  are  convulsions,  coma,  and  death. 

Cutaneous  eruptions  frequently  make  their  appearance  in  the  sec- 
ond week  of  the  attack,  during  convalescence.  All  the  varieties  of 
the  acute  exanthamata  have  been  noticed.  They  appear  in  a  varia- 
ble percentage  of  cases,  during  different  epidemics.  As  low  as  1%, 
and  as  high  as  46%  of  cases  have  been  noticed.  It  is  regarded  as  a 
favorable  sign,  and  is  usually  followed  by  an  improvement  in  the 
patient's  condition. 

Diphtheritic  inflammation  of  the  mucous  membrane  is  a  frequent 
cause  of  death,  the  upper  air-passages  suffering  most  frequently. 

Pleuritis  and  pneumonia  are  occasional  complications.  Suppura- 
tive  parotitis  is  less  frequent,  but  usually  results  fatally,  from  pyaemia. 

Diagnosis. — The  epidemic  character  of  the  disease,  and  its 
great  mortality,  should  prevent  error  in  diagnosis,  although,  at  the 
beginning  of  an  epidemic,  isolated  cases  may  not  be  recognized. 

Cholera  morbus  is  the  only  disease  with  which  it  can  be  con- 
founded. We  have  here  vomiting,  rice-water  discharges,  and  col- 
lapse, as  stated  under  the  head  of  cholerine,  the  presence  or  absence 
of  the  characteristic  bacilli  often  being  the  only  means  of  diagnosis 
between  that  variety  of  Asiatic  cholera  and  cholera  morbus. 

Poisoning  by  arsenic  or  antimony  differs  greatly  in  its  clinical 
features.  The  vomiting  is  painful,  and  preceded  by  burning  in 
the  stomach  and  oesophagus.  The  diarrhoea  is  not  of  the  rice-water 
variety,  but  mucous-  and  blood-stained.  The  poison  is  easily  detected 
by  analyzing  the  vomitus  or  dejections. 

Prognosis. — The  prognosis  is  very  unfavorable,  as  the  average 
mortality  is  50%.  Epidemics  vary  in  severity,  and  the  death  rate 
ranges  between  20%  and  80%.  The  disease  is  particularly  fatal 
among  the  aged,  young  children,  and  the  intemperate.  Where  chol- 
era develops  rapidly,  the  prognosis  is  grave,  a  gradual  increase  being 


206  SPECIFIC  INFECTIOUS  DISEASES. 

considered  a  favorable  sign.  The  mortality  is  always  greater  dur- 
ing the  early  history  of  an  epidemic,  the  virulence  of  the  disease 
seeming  to  be  mitigated  during  the  succeeding  months.  If  the  dis- 
ease does  not  find  favorable  conditions  for  its  further  development, 
its  intensity  is  gradually  exhausted.  The  death  rate  is  increased  as 
the  equator  is  approached. 

Treatment. — PROPHYLAXIS. — In  a  disease  where  one  man  may 
disseminate  the  seeds  of  an  epidemic,  preventive  measures  stand 
first.  Hygienic  conditions,  both  private  and  public,  have  an  impor- 
tant bearing  on  the  spread  of  cholera.  Cess-pools  and  privy  vaults 
should  be  disinfected,  and  all  standing  and  stagnant  water  should  be 
drained,  if  possible.  Filth  should  not  be  allowed  to  accumulate. 
The  water  supply  should  receive  attention;  where  there  is  a  possibil- 
ity of  infection,  the  water  should  be  boiled.  Quarantine  regulations 
should  be  enforced.  Of  the  value  of  a  rigid  quarantine,  we  have  had 
a  striking  example  in  the  cholera  epidemic  of  1892,  when,  at  New 
York,  the  disease  was  prevented  from  gaining  an  entrance  into  this 
country.  Cholera  stools  should  be  disinfected  and  buried.  Cloth- 
ing that  has  been  in  the  sick-room  should  be  thoroughly  disinfected, 
especially  when  soiled  by  the  patient  Everything  that  can  possi- 
bly spread  the  disease  should  be  cleansed  or  destroyed. 

The  medical  treatment  of  choleraic  diarrhcea  will  be  similar  to  that 
of  ordinary  serous  diarrhoea.  The  compound  tincture  of  cajeput 
(American  Dispensatory)  may  be  administered  in  fifteen-  or  twenty- 
drop  doses,  repeated  every  fifteen  or  twenty  minutes.  Instead  of 
this,  or  in  combination  with  it,  a  decoction  of  the  fresh  erigeron  can- 
adense  plant  may  be  taken  freely,  the  patient  being  made  to  drink  a 
wine-glassful  every  fifteen  or  twenty  minutes,  until  its  action  in 
arresting  the  evacuations  becomes  manifest.  Or,  instead,  one  may 
employ  three  grain  doses  of  arsenite  of  copper  6x,  repeated  every 
half  hour,  until  two  or  three  doses  have  been  taken,  then  every  hour, 
until  relief  follows. 

In  cholerine,  the  first  important  step  will  be  to  arrest  the  vomit- 
ing. This  we  will  probably  be  able  to  do  with  minute  doses  of  aco- 
nite and  rhus  tox.,  as  follows:  B  Specific  aconite  gtt.  v-vii,  rhus  tox. 
gtt  x-xv,  aqua  fiv.  M.,  and  order  a  teaspoonful  every  fifteen  min- 
utes, until  the  vomiting  ceases.  As  the  emesis  becomes  arrested,  the 
intestinal  evacuations  will  usually  cease.  Where  need  of  stimulants 
is  apparent,  we  may  derive  better  results  from  the  compound  tinc- 
ture of  cajeput,  used  as  already  advised. 

In  pronounced  cholera  such  remedies  must  be  aided  by  the  appli- 
cation of  brisk  cutaneous  stimulants,  by  means  of  sinapisms,  capsicum 
liniment,  or  friction  with  dry  capsicum  aided  by  dry  heat.  The 


ASIATIC  CHOLERA.  207 

hvpodermic  injection  of  a  third  of  a  grain  of  muriate  of  pilocarpine 
will  assist  in  equalizing  the  circulation  and  modifying  the  severity 
or  the  symptoms  where  there  is  much  elevation  of  temperature;  and 
where  algid  symptoms  are  prominent,  the  thirtieth  of  a  grain  of 
strychnia  may  be  employed,  the  dose  to  be  repeated  at  the  discre- 
tion of  the  practitioner.  To  relieve  the  urgent  thirst,  the  combina- 
tion of  aconite  and  rhus  tox.  will  be  found  excellent,  and  as  a  drink, 
a  cold  decoction  of  erigeron  canadense  will  be  best. 

The  patient  must  invariably  remain  in  the  recumbent  position,  and 
on  no  account  rise  to  stool,  or  for  any  other  purpose.  The  effort 
and  change  of  position  are  almost  certain  to  bring  on  aggravation  of 
the  intestinal  disturbance,  and  repetition  may  render  an  otherwise 
favorable  case  fatal. 

Occasionally,  acids  or  alkalies  may  be  specifically  indicated. 

The  diet  is  an  important  consideration,  both  from  a  prophylactic 
and  curative  standpoint.  As  cholera  is  a  zymotic  disease,  the  germs 
may  be  lurking  in  any  raw  food  or  drink  that  may  be  taken,  and 
strict  sterilization  of  everything  taken  should  be  observed,  and  no 
raw  food  or  drink  of  any  kind  allowed.  It  should  be  a  standard 
rule  to  boil  everything,  and  food  should  not  be  served  in  dishes 
whicli  have  not  been  washed  in  boiling  water.  Sterilized  water 
should  be  used  in  the  preparation  of  medicines,  and  for  drinking,  and 
rinsing  the  mouth.  As  cholera  germs  do  not  thrive  in  acid  media, 
acid  beverages  may  be  drunk  freely,  if  they  do  not  seem  to  aggravate 
the  g  istro-intestinal  disturbance.  As  a  prophylactic,  sour  lemonade, 
further  acidulated  with  a  few  drops  of  sulphuric  acid,  has  been 
highly  recommended.  Vinegar,  lime  juice,  and  other  sour  drinks 
may  be  employed  lor  the  same  purpose. 

As  alkaline  fermentation  in  the  stomach  favors  infection,  only 
plain  food  should  be  eaten  during  the  prevalence  of  an  epidemic, 
pastries  and  fried  dishes  being  avoided. 

Lastly,  during  a  cholera  epidemic,  it  is  best  to  avoid  everything 
likely  to  ordinarily  produce  diarrhoea.  During  the  active  period  of 
the  disease,  there  is  little  use  of  attempting  to  administer  nourish- 
ment to  the  patient,  as  the  diarrhoea  and  intestinal  evacuations  are 
thereby  only  increased.  Now,  hypodermic  injections  of  warm  salt 
water  (a  teaspoonful  to  a  pint  of  boiled  water)  should  be  freely 
made,  into  the  thighs  and  abdomen,  to  replace  the  drain  upon  the 
blood  caused  by  the  serous  diarrhoea. 

When  vomiting  ceases,  and  the  symptoms  of  collapse  abate,  small 
quantities  of  fluid  nourishment  may  be  gradually  and  cautiously 
administered.  A  teaspoonful  or  two  of  pancreatinised  milk,  koumiss, 
beef  tea,  or  fresh  beef  juice,  may  at  first  be  given.  If  this  be 


208 


SPECIFIC  INFECTIOUS  DISEASES. 


retained,  a  little  more  may  be  administered  after  a  brief  interval, 
the  quantities  being  gradually  increased.  Horlick's  milk  may  now 
be  given  in  small  quantities.  As  the  stomach  remains  feeble  and 
sensitive  for  a  long  time,  the  amount  and  quality  of  the  food  must 
be  gradually  advanced  to  milk,  egg  albumen  in  brandy,  or  cham- 
pagne, and  other  nourishing  fluid  food,  before  solid  food  is  allowed. 

XIX.  YELLOW  FEVER. 

Synonyms. — Febris  Flava;  Typhus  Icterodes;  Black  Vomit; 
Yellow  Jack.  Spanish,  Vomito  Nigro. 

Definition. — An  infectious,  contagious  disease,  characterized 
by  sudden  invasion,  and  fastigium  of  from  two  to  seven  days'  dura- 
tion, with  termination  by  lysis,  the  fall  of  temperature  being  attended 
by  a  remarkable  slowing  of  the  pulse,  this  decline  being  followed  by 
a  second  rise  in  temperature,  attended  by  phenomenal  icterus,  hema- 
temesis,  albuminuria,  suppression  of  urine,  and  rapid  and  profound 
prostration. 

Etiology. — This  disease  seems  to  be  indigenous  to  the  eastern 
sea-coast  of  tropical  America,  especially  the  West  Indies,  where  it 
prevails  endemically  throughout  the  seasons,  and  occasionally  spreads 
as  an  epidemic,  during  periods  of  remarkable  territorial  receptivity, 
along  lines  of  travel,  into  the  temperate  zones.  It  is  a  disease  of  hot 
climate,  filth,  moisture,  and  a  low  altitude,  the  seaports  of  the  trop- 
ical regions  being  its  principal  places  of  resort,  though  at  the  pres- 
ent time  railroads  offer  ready  means  of  transportation  into  the  inte- 
rior, during  severe  epidemics. 

The  principle  of  infection  is  believed  to  be  a  microorganism, 
though  all  attempts  to  isolate  it  have  thus  far  proven  futile.  Accord- 
ing to  Dr.  John  Guiteras  (Keat- 
ing's  Cyclopaedia)  the  disease  is 
mild  in  children  in  its  native 
haunts — the  West  Indies — being 
often  unrecognized  by  diagnosti- 
cians, and  as  common  as  measles 
is  among  children  in  our  own  com- 
munity, nearly  all  adults  in  these 
communities  being  protected  by  a 
previous  attack  during  childhood. 
Colored  races  seem  especially 
prone  to  mild  attacks  of  it  while 
young,  and  are  therefore  protected 
from  a  second  attack  in  later  life, 
rendering  it  a  notorious  fact  that  colored  races  enjoy  a  marked  immu- 


YELLOW  FEVER.  209 

nity.  Whether  colored  people  born  and  bred  in  the  North  enjoy 
any  more  immunity  than  white  persons,  may  be  a  matter  of  question. 
Like  measles,  it  seems  that  an  attack  in  adult  life  is  much  more 
severe  than  in  childhood,  and  when  adults  who  do  not  enjoy  the 
advantage  of  protection  come  in  contact  with  it,  it  is  remarkably  vir- 
ulent and  fatal.  It  is  said  that  Creoles  are  less  liable  to  the  disease 
than  whites,  negroes  less  than  Creoles,  and  Indians  of  tropical  regions 
least  of  all.  That  yellow  fever  is  not  a  malarious  disease  is  abun- 
dantly proven  by  the  fact  that  malarial  fever  is  never  contracted  upon 
the  high  seas,  it  being  distinctively  telluric  in  origin,  while  yellow 
fever  may  be  spread  on  shipboard,  provided  fomites  have  been  taken 
on  in  port,  and  decimate  the  whole  crew,  as  well  as  contaminate 
those  from  other  vessels  who  may  chance  to  go  on  board,  for  any 
protracted  time. 

It  is  asserted  by  some  that  yellow  fever  is  not  directly  conta- 
gious from  one  person  to  another,  but  that  it  is  conveyed  by  fomites, 
the  contagium  seeming  to  accumulate  infective  power  as  it  is  nurtured 
by  confinement  and  other  favoring  causes,  such  as  decomposition, 
warmth,  and  moisture.  It  is  certain  that  plenty  of  fresh  air  is  abont 
as  reliable  a  preventive  of  the  disease  (save  strict  quarantine)  as 
any  that  has  been  tried,  and  it  would  therefore  seem  that  the  infec- 
tion gains  virulency  after  leaving  a  subject,  through  such  causes. 
Severe  epidemics  in  temperate  regions  <are  usually  checked  by  the 
first  frosts,  and  a  pronounced  "freeze"  stamps  it  out  at  once. 

Occasionally  the  disease  invades  places  far  north  of  its  native 
habitat,  a  severe  epidemic  having  occurred  in  Philadelphia,  in  1793, 
four  thousand,  out  of  eleven  thousand  persons  attacked,  perishing. 
It  first  appeared  in  the  United  States  in  Boston,  in  1693,  and  has 
since  appeared  occasionally  at  other  points,  sometimes  in  severe  epi- 
demics, up  to  the  present  time.  It  has  been  conveyed  as  far  north 
as  Portsmouth,  New  Hampshire.  Occasionally  the  infection  is  win- 
tered over,  and  appears  the  following  season  with  unabated  severity, 
as  occurred  at  Memphis  in  1879,  when  it  hibernated.  During  late 
epidemics,  there  has  been  a  tendency  for  the  disease  to  follow  lines 
of  railway  into  the  interior  from  southern  seaports,  severe  and  fatal 
cases  occurring  far  inland. 

Pathology. — The  anatomical  changes  of  yellow  fever  are  found 
in  all  parts  of  the  body,  though  the  most  marked  disorganization 
occurs  in  the  liver.  This  organ  is  found  to  be  markedly  yellow  in 
appearance  (resembling  box-wood  in  color).  Disorganization  of  the 
parenchyma  has  occurred,  necrotic  masses  being  found  in  and 
between  the  cells,  with  fatty  degeneration,  resulting  in  the  disten- 
sion of  these  bodies  with  oil.  In  other  cases,  the  degeneration  is 


210 


SPECIFIC  INFECTIOUS  DISEASES. 


granular,  the  nuclei  of  the  hepatic  cells  being  obscured  or  entirely 
destroyed.  The  organ  breaks  down  on  firm  pressure,  and  on  section 
the  tissues  are  found  drier  than  normal,  less  blood  than  usual  being 
in  the  vessels. 

The  skin  is  markedly  yellow,  the  color  varying  from  dark  orange 
to  a  bright  golden  yellow,  and  petechise,  eruptions,  pustules,  ecchy- 
moses,  and  extravasations  are  liable  to  be  found  upon  the  surface. 
The  mucous  membranes  may  also  present  a  yellowish  tinge.  The  adi- 
pose tissue,  too,  is  deeply  stained  an  icteric  hue. 

Important  changes  are  found  to  have  taken  place  in  the  blood,  to 
these  the  marked  yellowness  of  the  tissues  being  due.  The  red  cor- 
puscles are  broken  down  in  many  instances,  or  they  are  serrated  and 
shriveled.  The  broken-up  contents  are  altered,  and  the  hematin  is 


converted  into  bile  pigment,  this  staining  the  tissues  the  character- 
istic yellow.  Ammoniacal  decomposition  sets  in  soon  after  the  with- 
drawal of  the  blood  from  the  body,  due  to  alteration  in  its  saline 
constituents,  and  it  is  found  that  there  is  partial  loss  of  coagulating 
quality,  the  fibrin-factors  having  apparently  lost  their  function. 

There  is  active  catarrh  of  the  mucous  membrane  of  the  upper 
portion  of  the  alimentary  canal,  with  ecchymosis  and  varicosis  of  the 
superficial  veins,  the  extravasations  being  largely  due  to  the  forcible 
vomiting  of  the  disease.  The  urinary  tract  also  affords  evidence  of 
similar  changes,  the  kidneys  being  the  seat  of  parenchymatous 
inflammation,  with  fatty  degeneration  and  breaking  down  of  tissue. 
Infarctions  are  found  in  the  lungs,  pulmonary  apoplexy  sometimes 


YELLOW  FEVER.  211 

occurring.  Pleural  ecchymosis,  with  effusion  of  bloody  serum  into 
the  pleural  sac,  is  also  one  of  the  occasional  occurrences. 

The  musdes  are  darker  than  normal,  their  dark  color  contrasting 
markedly  with  the  yellow  color  of  the  skin  and  adipose  tissues. 
Marked  granular  degeneration  is  found  to  have  taken  place  in  the 
histological  elements,  this  probably  being  due  rather  to  some  spe- 
cific poison  (ptomaine)  generated  during  the  disease  than  to  simple 
pyresial  changes,  as  the  temperature  in  yellow  fever  is  not  high 
enough,  nor  sufficiently  prolonged,  to  account  for  the  very  decided 
morbid  alterations. 

The  heart  is  soft,  friable,  and  flabby,  and  the  muscle  is  found  to 
have  undergone  more  or  less  granular  degeneration.  The  cavities 
contain  considerable  broken-down,  fluid  blood,  with  occasional  clots. 
Guite"ras  remarks  that  he  has  always  fouiid  the  left  heart  contracted. 
Neither  the  endocardium  nor  pericardium  bear  evidence  of  inflam- 
matory action. 

The  spleen  is  not  prominently  altered,  though  it  may  be  slightly 
congested,  softer,  more  friable  than  natural,  and  of  darker  color. 

Slight  changes  may  be  noticed  in  the  brain  and  spinal  cord.  These 
may  consist  of  hypersemia  (not  marked),  punctate  extravasations  in 
the  meninges,  and  occasionally,  effusions  in  the  lumbar  and  sacral 
regions. 

Symptoms. — The  stage  of  incubation  lasts  from  a  few  days  to  a 
week.  It  may,  in  exceptional  cases,  extend  to  fourteen  days,  but 
they  are  rare  where  the  period  after  exposure  extends  beyond  a 
week.  In  cases  where  but  a  short  time  elapses  after  exposure,  the 
disease  usually  proves  very  virulent. 

There  is  a  marked  difference  between  the  course  of  a  mild  attack 
of  yellow  fever  and  a  severe  one.  In  the  mild  attack,  the  severest 
symptoms  arise  during  the  initial  fever,  the  remission  being  followed 
by  but  slight  febrile  symptoms,  and  often  these  are  absent.  In  all 
probability  the  secondary  fever  is  the  result  of  the  poisoning  of  the 
system  by  the  ptomaines  generated  during  the  first  attack,  by  the 
germs  of  infection  which  excited  the  primary  fever. 

The  invasion  is  usually  sudden,  consisting  of  a  marked  chill, 
speedily  followed  by  fever,  attended  by  severe  pains  in  the  head,  back, 
and  limbs,  the  pain  being  notably  severe  in  the  back  and  legs;  and 
there  is  nausea  and  vomiting.  The  temperature  rises  rapidly  at 
first,  though  yellow  fever  is  not  ordinarily  a  disease  of  very  great 
pyrexia.  The  pulse  becomes  full,  strong,  and  rapid  at  first,  though 
it  soon  weakens,  the  skin  being  dry  (sometimes  moist)  and  hot,  and 
secretion  arrested  generally.  The  eyes  early  present  a  peculiar  shin- 
ing appearance,  being  markedly  suffused,  and  this,  with  the  bronzed 


212 


SPECIFIC  INFECTIOUS  DISEASES. 


or  yellowed  color  of  the  countenance,  and  staring  look,  impart  to  the 
visage  a  remarkably  sodden  and  dejected  aspect  The  tongue  is 
covered  with  a  thick  white  fur  from  the  outset,  except  at  the  tip  and 
edges,  which  are  red  and  bare.  The  bowels  are  usually  constipated, 
though  hemorrhagic  diarrhoea  may  be  present.  The  mind  is  usually 
clear  to  the  last,  though  delirium  may  set  in  in  the  late  stage,  the 
patient  being  wild  and  restless,  and  determined  to  get  out  of  bed. 
By  the  third  or  fourth  day  of  the  disease,  the  temperature  will  have 
reached  its  height,  the  thermometer  registering  hardly  ever  more 
than  104°  to  105°  F.,  though  it  may  rise  as  high  as  110°.  When  the 

fourth  day  has  been  reached, 
the  temperature  declines  rap- 
idly, running  down  to  near 
the  normal  line,  marking  a 
distinct  remission,  which  may 
last  for  two  or  three  hours, 
or  two  or  three  days.  This 
constitutes  the  period  of 
calm,  the  patient  being  free 
from  suffering,  except  that  of 
marked  prostration,  after 
which  a  second  rise  in  tem- 
perature begins.  This  usu- 
ally begins  without  a  chill, 
and  rises  more  gradually  than 
during  the  invasion.  The 
temperature  may  now  again 
reach  104°  or  105°,  where  it  remains  a  day  or  two,  to  fall  again,  con- 
tinuing to  do  so,  in  favorable  cases,  until  the  normal  point  is  reached. 
The  pulse  of  yellow  fever,  after  the  first  few  days,  is  said  to  be 
peculiar,  a  sensation  being  imparted  to  the  finger  as  though  there 
were  gas  in  the  arteries,  the  name  "gaseous  pulse"  being  applied  to 
it.  It  is  now  markedly  compressible.  It  hardly  ranges  above  110 
per  minute,  during  the  fever,  and,  in  mild  cases,  it  may  not  be  more 
than  four  or  five  beats  above  the  normal  rate.  During  the  remis- 
sion, or  stage  of  calm,  it  falls  remarkably,  lowering  to  a  thirty  or 
forty  rate  per  minute. 

About  the  third  day  the  icterus  begins  to  appear,  being  observ- 
able at  first  in  the  sclera,  and  rapidly  spreading  over  the  body.  The 
color  is  deep,  like  that  of  pyaemia,  almost  bronzed  in  appearance.  It 
is  due  to  staining  of  the  skin  from  the  pigment  formed  from  the  ele- 
ments of  broken-down  blood,  which  are  deposited  in  the  tissues, 
and.  not  from  hepatic  secretions.  The  perspiration  now  stains  the 


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TEMPERATUBE  CURVE  IN  YELLOW  FKVEB. 


YELLOW  FEVEK.  213 

linen  yellow,  and  a  cadaveric  odor  emanates  from  the  body.  When 
the  third  stage  is  reached,  the  color  becomes  a  mahogany  hue. 

The  vomiting  is  a  marked  feature  of  the  disease,  it  beginning 
immediately  after  the  chill,  and  persisting  during  both  febrile  stages. 
It  may  be  severe  or  not,  in  many  mild  cases  being  restricted  to  the 
rejection  of  food,  as  soon  as  taken.  In  other  cases,  the  contents  of 
the  stomach  are  ejected  first,  then  a  yellowish-green  material,  of 
alkaline  reaction,  is  projected,  the  alkalinity  being  due  to  ammoniacal 
decomposition  of  the  blood.  If  the  case  is  severe  and  ominous,  there 
is  soon  hemorrhage  into  the  stomach,  and  black  contents  are  ejected, 
constituting  the  characteristic  "black  vomit"  of  this  disease.  If, 
instead  of  this,  yellowish-green,  alkaline  material  continue  to  be 
ejected,  the  symptoms  may  be  considered  more  favorable. 

The  urine  is  scanty  early  in  the  disease,  and,  as  the  morbid 
changes  progress  in  the  kidneys,  traces  of  albumin  may  be  found. 
It  is  acid  in  reaction  at  first,  but  as  ammoniacal  decomposition  sets 
in,  it  becomes  alkaline,  and  colored  with  bile-pigment,  which  becomes 
more  abundant  as  the  disease  progresses.  If  not  present  before, 
the  bile  pigment  makes  its  appearance  during  the  stage  of  remission, 
and  soon  fatty  casts,  leucin,  and  ty rosin  will  appear  in  the  secretion. 
A  strong  urinous  odor  now  pervades  the  entire  body.  Compkte  sup- 
pression of  urine  will  appear  in  fatal  cases,  and  this  symptom  may 
be  regarded  as  an  almost  certain  percursor  of  a  fatal  issue,  it  being 
asserted  by  good  authority  that,  though  cases  with  black  vomit  may 
recover,  those  with  suppression  of  urine  are  almost  certain  not  to. 

Diagnosis. — In  severe  cases  occurring  during  an  epidemic, 
there  can  hardly  be  any  danger  of  mistake  in  diagnosis.  The  severe 
attack  with  vomiting,  the  peculiar  suffused  and  staring  expression  of 
the  eye,  the  marked  icterus,  coming  on  the  third  day,  the  early 
decline  of  the  fever  in  the  first  stage,  with  the  remarkable  slowing  of 
the  pulse,  and  its  peculiar  compressibility  (gaseous  pulse),  the 
black  vomit,  the  mahogany  color  in  the  last  stage,  are  not  all  found 
in  other  forms  of  infectious  fevers.  The  history  of  the  case  will  fur- 
nish sufficient  testimony  in  the  early  part  of  most  attacks  to  enable 
the  physician  to  be  on  his  guard  against  a  careless  diagnosis.  Dr. 
Guiteras  asserts  that  endemic  cases  occurring  among  children  are 
not  so  easily  recognized.  Many  of  the  distinctive  symptoms  are  not 
prominent  here,  and  it  may  be  mistaken  for  ephemeral  fever  due  to 
heat,  unless  considerable  care  is  observed. 

Prognosis. — Some  epidemics  are  extremely  fatal,  others  not  so 
markedly  so.  The  epidemic  influence  (territorial  receptivity)  will 
determine,  to  great  extent,  the  amount  of  mortality  to  be  expected. 
One  fact  is  always  to  be  recollected,  viz.,  the  disease  is  ever  to  be 


214  SPECIFIC  INFECTIOUS  DISEASES. 

dreaded  when  wandering  from  its  indigenous  haunts,  or  when  affect- 
ing adults  who  have  not  been  protected  by  a  former  attack,  especially 
the  unacclimated.  Where  the  yellowish-green  vomit  continues 
throughout  the  disease,  the  case  may  ordinarily  be  considered  a 
favorable  one,  and  when  this  is  replaced  by  the  black  vomit,  it  is 
always  grave,  though  recovery  may  ensue.  Marked  scantiness  of 
the  urine  is  an  unfavorable  symptom,  and  when  this  secretion 
becomes  suppressed,  there  can  be  scarcely  any  hope  of  a  favorable 
termination.  A  gradual  subsidence  of  the  vomiting,  and  diminution 
of  the  amount  of  albumin  in  the  urine,  may  be  considered  as  favor- 
able signs.  Convalescence  is  remarkably  slow  in  this  disease,  six 
months  being  required  to  thoroughly  recuperate  from  it. 

Treatment. — Prophylaxis  is  first  to  be  considered,  and  this  can 
best  be  assured  by  strict  quarantine.  Not  only  all  individuals  who 
have  been  exposed  or  who  may  be  affected,  as  well  as  all  articles  of 
clothing  that  have  been  about  the  disease,  should  be  strictly  excluded 
from  contact  with  those  who  have  not  been  infected,  but  everything 
surrounding  the  disease  should  be  strictly  avoided  by  the  well  who 
do  not  possess  immunity.  Pure,  cool  air,  in  elevated  regions,  is  also 
a  good  prophylactic,  as  it  will  be  remembered  that  the  disease  is  one 
of  filth,  warmth,  and  decomposition.  Camping  out  is  practiced  much 
upon  these  principles  in  yellow  fever  regions,  when  the  disease  pre- 
vails as  an  epidemic.  Even  here,  however,  a  strict  quarantine 
should  be  practiced. 

The  experience  of  Eclectic  practitioners  with  this  disease  seems 
to  have  been  very  limited.  Goss  states  that  the  treatment  should 
consist  largely  of  the  use  of  antiseptics,  and  recommends  baptisia  as 
a  leading  remedy.  Aconite  for  the  fever,  belladonna,  when  meningeal 
irritation  is  indicated,  minute  doses  of  arsenic  for  the  vomiting,  and 
camphor,  during  the  stage  of  collapse,  are  the  other  principal  reme- 
dies suggested  by  this  author. 

The  disease  is  evidently  one  where  necrotic  changes  are  at  the 
foundation  of  the  serious  mischief  which  results.  The  breaking 
down  of  the  blood,  the  destructive  changes  in  the  liver  and  kidneys, 
the  black  vomit,  these  are  all  due  to  a  necrotic  tendency,  and  sug- 
gest the  most  reliable  remedy  obtainable  to  arrest  it.  If  we  can 
find  a  remedy  which  possesses  sedative  properties  combined  with 
those  of  an  antiseptic,  anti-necrotic,  and  stimulant,  we  shall  have  the 
very  remedy  required.  It  will  be  recollected  that  the  second  stage 
of  this  disease  is  attended  by  a  very  slow  and  feeble  pulse,  and  there 
is  therefore  a  decided  objection  to  any  sedative  which  does  not  pos- 
sess, at  the  same  time,  stimulating  properties.  I  think  that  we  pos- 
sess one  remedy  which  is  well  adapted,  in  its  properties,  to  the  com- 


YELLOW  FEVER  215 

bination  of  requirements  suggested  by  the  pathology  of  this  disease, 
and  this  is  echinacea.  I  do  not  write  from  any  experimental  knowl- 
edge of  the  disease,  for  I  have  never  seen  a  case ;  but  I  observe  that 
those  who  have  written  from  experience  seem  to  be  sadly  at  sea, 
concerning  its  medication,  and  believe  this  remedy  alone  would 
accomplish  more  than  most  of  the  routine  treatment  usually 
prescribed. 

Baptisia  also  exerts  an  influence  of  this  kind,  though  it  is  slow 
in  action,  when  compared  with  echinacea.  The  two  remedies  might 
probably  be  used  together  with  profit,  the  combination  being  admin- 
istered perseveringly,  throughout  the  treatment. 

Two  remedies,  exerting  a  similar  influence,  and  highly  prized  by 
the  homeopaths,  are  lachesis  and  crotalus  hor.  Crotalus  hor.  is  espe- 
cially indicated  where  a  strong  hemorrhagic  tendency  is  suggested 
by  ecchymoses,  extravasations,  and  black  vomit.  Dr.  Holcombe, 
of  New  Orleans  (as  well  as  others),  has  used  it  in  such  cases  with 
excellent  success.  The  6x  of  lachesis,  and  the  3x  of  crotalus  hor. 
may  be  employed,  both  being  obtainable  at  almost  any  homeopathic 
pharmacy. 

The  condition  of  the  tongue  early  in  the  disease,  as  well  as  the 
vomiting,  would  suggest  rhus  fox.,  and  this  might  be  combined  with 
minute  doses  of  aconite.  Where  the  vomiting  prevents  the  retention 
of  remedies  per  stomach,  hypodermic  injections  of  specific  echinacea 
would  be  philosophical  treatment,  and  it  could  do  no  harm,  at  least. 

Scudder  recommends  the  use  of  an  emetic  where  the  tongue  is 
heavily  coated,  and  this  might  be  advisable  if  there  were  not  too  much 
gastric  irritation  in  the  beginning.  In  this  disease,  however,  the 
morbid  condition  lies  far  beyond  the  reach  of  remedies  which  exert 
a  local  influence  upon  the  stomach.  The  blood-corpuscles  first,  and 
later,  the  tissues  of  important  vital  organs,  become  necrotic,  and  unless 
we  can  find  a  remedy  which  will  neutralize  this  tendency  early, 
treatment  can  be  of  but  little  avail,  in  severe  cases. 

The  hypodermic  use  of  pilocarpine  (l-3d  grain)  may  be  resorted 
to  where  pyrexial  action  is  dangerously  high,  and  strychnia  (l-30th 
t>rain)  may  be  administered  in  the  same  manner,  when  a  power- 
ful stimulant  is  required. 

There  may  be  malarial  complication,  demanding  treatment  for 
this  phase  of  the  disease,  but  yellow  fever  is  not  a  malarial  disease 
of  itself,  as  it  arises  and  prevails  where  no  malaria  is  present.  How- 
ever, arseniate  of  quinia  3x,  or  sulphate  of  quinia,  may  be  required 
during  convalescence. 

Cathartics  should  be  avoided,  the  bowels  being  evacuated  with 
enemata,  when  this  is  necessary. 


216  SPECIFIC  INFECTIOUS  DISEASES. 

The  diet  should  be  in  digestible  and  nutritious  form.  This  will 
comprehend  the  use  of  such  articles  as  milk,  animal  broths,  pan- 
oreatinized  milk,  Horlick's  malted  milk,  etc.  No  solid  food  should 
be  taken  for  several  weeks  after  convalescence  has  begun,  and  fruits 
and  vegetables  should  be  avoided  during  this  time. 

-'XX.  MALARIAL  FEVER. 

Synonyms. — Marsh  Fever;  Swamp  Fever;  Paludal  Fever. 

Definition. — A  specific,  non-contagious  disease,  caused  by  the 
hematazoa  of  Laverau,  and  characterized  by  periodical  paroxysms 
of  fever,  tendency  to  enlargement  of  the  spleen,  with  general  conges- 
tion of  the  portal  system,  and  progressive  anaemia. 

Etiology. — From  almost  time  immemorial,  the  origin  of  mala- 
rial fever  has  been  ascribed  to  the  presence  of  decaying  vegetation; 
and  moisture  and  warmth  being  necessary  to  vegetable  decay,  and 
such  surroundings  being  the  localities  where  malarial  fevers  are  most 
prevalent,  the  natural  inference  has  been  that  such  influence  was 
responsible  for  the  condition  of  the  system  which  gave  rise  to  them. 
It  was  thus  widely  believed  that  gaseous  emanations,  arising  from 
such  material,  constituted  the  materies  niorbi. 

But  the  microscope  has  enlightened  us  upon  this  subject,  and  it 
is  now  known  that  the  blood  of  a  person  suffering  from  malaria  inva- 
riably contains  some  form  of  a  species  of  hematozoa  (the  plasmodium 
of  Laverau) — a  living  creature,  which  undergoes  various  processes  of 
development  in  the  blood,  through  which  the  red  corpuscles  are 
destroyed  and  ansemic  conditions  brought  about,  the  various  phe- 
nomena of  fever  attending,  as  the  results  of  the  presence  of  this 
parasite. 

Knowledge  of  other  parasitic  animal  forms  which  maintain  an 
existence  in  the  blood,  assists  us  in  drawing  philosophical  deduc- 
tions as  to  the  cause  of  a  disease,  upon  the  nature  of  which  medical 
men  have  differed  for  centuries. 

The  life  history  of  the  filaria  is  interesting,  in  illustrating  the 
instrumentality  of  intermediate  influences  sometimes  concerned  in 
the  transmission  of  infectious  diseases,  and  it  is  also  suggestive  of 
the  manner  in  which  the  plasmodium  malarias — which  belongs  to  the 
same  family — may  be  transmitted. 

The  filaria  nocturna,  which  inhabits  the  human  circulation,  in 
hot  countries,  is  taken  up  by  the  mosquito  (from  the  human  circula- 
tion), during  its  blood-sucking  process,  and  afterward,  when  the 
insect  flies  away  to  the  water  and  dies,  after  gorging  itself,  is  released 
from  the  decaying  body  into  the  water,  to  be  afterward  taken,  with 


MATERIAL  FEVER.  217 

drinking  water,  into  the  human  stomach  alive,  and  able  to  enter  the 
circulation  of  the  new  host,  there  to  undergo  reproduction.  Such 
being  the  facts  with  regard  to  one  species  of  hematozoa,  there  is 
great  probability  that  a  similar  method  of  transmission  with  another 
may  be  possible. 

There  are  some  facts  that  give  such  a  proposition  color,  as 
regards  the  plasmodium  malarias.  Among  them  may  be  mentioned 
that  out  of  many  families  residing  in  malarious  neighborhoods,  it 
is  known  that  most  of  those  escape  malaria,  during  its  prevalence, 
who  confine  themselves  strictly  to  boiled  water,  for  potable  purposes. 
Another  is,  that  altitudes  and  latitudes  where  the  mosquito  does 
not  exist  are  largely  free  from  malaria,  while  such  regions  as  favor 
its  existence  most  are  the  ones  where  malaria  prevails  most 
extensively. 

The  author  finds  the  foregoing  views,  penned  several  years  ago 
(1895,  not  published,  but  presented  to  his  class  in  the  winter  of 
1895-96),  have  been  put  forward  by  Dr.  Manson,  March  14,  1896, 
as  published  in  the  British  Medical  Journal.  It  is  certainly  a  very 
rational  view  of  the  matter. 

At  Dr.  Manson's  request,  Surgeon-Major  Boss  performed  several 
experiments  to  test  this  theory. 

Upon  placing  a  person  who  was  affected  by  malaria,  and  in 
whose  blood  the  plasmodium  was  demonstrable,  under  a  net  with 
mosquitoes,  raised  from  the  eggs,  and  confined,  so  they  could  not 
obtain  food  elsewhere,  and  allowing  them  to  suck  his  blood,  the 
mosquitoes  being  afterward  killed  and  their  stomachs  examined 
the  result  was  that  the  hematozoa  of  malaria  were  found  there  in 
plentiful  numbers,  undigested  and  alive,  and  nearly  all  of  them  pro-' 
ceeded  to  develop  rapidly  into  mature  forms.  Some  of  these  mos- 
quitoes were  allowed  to  deposit  their  eggs  in  water,  where  they  died, 
and  this  water  was  afterward  drank  by  a  native.  Within  eleven 
days  afterward,  the  native  developed  fever,  and  his  blood  was  found 
to  contain  organisms.  The  second  time,  however,  the  experiment 
proved  without  result  We  must  regard  this,  then,  as  only  a  theory, 
to  be  substantiated  or  disproven  in  the  future.  Against  it,  we  have 
the  positive  assertions  of  reliable  physicians  that  malaria  has  been 
known  by  them  to  prevail  extensively  in  mountainous  regions,  where 
the  mosquito  was  never  (or  hardly  ever)  seen. 

The  plasmodium  malarice  (hematozoon  of  Laveran)  appears  in  the 
blood  in  a  variety  of  forms,  these  probably  representing  different 
stages  of  development,  though  it  is  likely  that  there  are  several 
varieties  of  malaria-producing  organisms  belonging  to  one  family 
but  of  different  species.  Their  development  is  as  follows: 


218 


SPECIFIC  INFECTIOUS  DISEASES. 


7<V7VMco*«»USct/<.AH   f  osien 
' 


The  spore,  floating  in  the  blood,  attaches  itself  to  a  reel  corpuscle, 
and  finally  penetrates  it,  to  absorb,  in  this  situation,  nourishment  from 
the  corpuscle,  and  grow  to  mature  form,  pigment  granules,  due  to 
the  hemaglobiu  absorbed  from  the  blood-corpuscle,  accumulating 
iu  its  center.  Segmentation  of  the  nematozoon  now  succeeds,  and 
the  spores  are  set  free  (  by  the  destruction  of  the  red  corpuscle ),  to 
attack  other  corpuscles  in  their  turn.  Crescentric  bodies  form,  repre- 
senting one  phase  of  these  parasites,  and  it  is  believed  by  some  that 

MALARIA,  they   are    inter- 

changeable  into 
sphere  s — t  h  e 
developed 
plasmodium  or 
/  /  }  hematozoon. 
'  /  X  Some  believe 
that  the  cres- 
cents are  associated  chiefly  with  irregular  forms  of  malarial  fever, 
and  malarial  cachexia.  Flagella,  or  lash-like  processes,  develop  from 
hematozoa  which  are  fully  matured. 

Golgi,  who  leads  the  Italian  school  of  bacteriologists,  believes 
that  the  different  Jorms  of  malarial  fever  depend  upon  different  varie- 
ties of  hematozoa;  that  the  tertian  form  depends  upon  a  variety  that 
completes  its  development  in  forty-eight  hours,  the  quartan  upon 
one  which  develops  within  seventy-two  hours,  etc.  Other  types  are 
supposed  to  be  due  to  the  maturity  of  two  or  more  generations  of 
the  same  variety  occurring  at  different  periods ;  as,  for  instance,  quo- 
tidian ague  representing  the  maturity  of  two  generations  of  the  ter- 
tian variety  alternately.  Probably,  also,  there  may  be  a  mixture  of 
varieties  to  still  more  complicate  matters,  and  embarrass  regularity 
of  paroxysms. 

Differentiation  may  be  made  between  the  tertian  and  quartan 
varieties  during  the  stage  of  sporulation.  Then,  the  spores  are  found 
to  be  more  numerous  in  the  tertian  variety  than  in  the  quartan,  while 
in  the  latter  they  are  larger. 

Maliynant  forms  of  malarial  fever  are  also  to  be  differentiated 
from  others  by  the  microorganisms.  Not  only  are  the  hematozoa 
smaller,  but  the  spores  are  also  smaller,  and  less  numerous,  while 
the  corpuscles  shrivel,  when  attacked. 

It  is  believed  that  at  the  time  of  maturation  of  the  parasite  and 
the  liberation  of  spores,  a  toxine  is  set  free,  which  originates  the 
paroxysm,  the  variety  of  parasites  present  (or  certain  combinations 
of  varieties)  determining  whether  the  paroxysm  be  quotidian,  ter- 
tian, quartan,  etc.  When  a  patient  removes  from  malarious  sur- 
roundings, the  persistency  of  the  disease  depends  upon  the  presence 


MALARIAL  FEVER.  219 

of  the  ehraatozoa  in  the  blood,  certain  forms  probably  being  more 
permanent  than  others. 

CONDITIONS  WHICH  PREDISPOSE  TO  ATTACKS  OF  MALARIA. —  Tempera- 
ture exerts  an  important  influence.  An  average  temperature  of  58°  is 
necessary  for  its  development,  and  it  does  not  prevail  epidemically 
short  of  an  average  temperature  of  60°  F.  Moisture  is  another  essen- 
tial, and  the  regions  where  it  is  most  prevalent  are  those  about 
marshy  districts,  where,  during  the  heated  season,  the  water  becomes 
low  and  stagnant.  Salt  water  is  not  malarious,  but  marshes  of  salt 
and  fresh  water  combined — as  where  rivers  empty  into  salt  marshes 
— are  liable  to  be  very  much  so.  Neio  soil,  freshly  exposed  to  the 
atmosphere,  as  when  prairies  have  been  turned  up  by  the  plow,  or 
extensive  excavations  are  being  carried  on  during  the  building  of 
railroads,  canals,  etc.,  is  very  liable  to  provoke  epidemics  of  the  dis- 
ease. Regions  where  there  is  a  non-porous  sub-soil,  are  usually 
malarious,  as  the  wells  are  shallow,  and  the  drinking  water  comes 
from  near  the  surface.  Vegetable  decomposition  has  been  supposed 
to  figure  extensively  in  the  propagation  of  malaria,  but  it  is  highly 
probable  that  the  presence  of  a  large  amount  of  such  material  may 
be  coincident  with  other  conditions  upon  which  the  infection  actu- 
ally depends.  Extensive  irrigation  with  fresh  water  under  warm 
sunshine,  continued  day  after  day,  or  often  enough  to  keep  the 
ground  moist,  is  almost  certain  to  be  attended  by  the  appearance  of 
malarious  diseases  in  the  neighborhood.  The  infection  may  be 
wafted  by  the  wind  for  several  miles,  when  conditions  are  favorable. 
The  following  incident  suggests  what  might  be  expected  under  sim- 
ilar circumstances:  The  crew  of  a  ship  which  anchored  within  four 
and  a  half  miles  of  a  malarious  shore,  and  remained  there  for  several 
days,  were  finally  attacked  by  malaria,  six  days  after  the  wind  had 
blown  off  the  shore  for  a  short  time.  None  of  the  crew  were  ailing 
when  the  anchorage  was  made,  and  all  were  well  until  now.  As 
malaria  is  a  disease  of  the  land,  never  originating  on  the  high  seas, 
the  evidence  that  the  disease  arose  in  this  instance  through  the 
agency  of  the  wind,  seems  conclusive.  Night  air  is  almost  cer- 
tain to  provoke  aggravation  of  ordinary  malarious  infection,  upon 
repeated  exposure  to  it. 

CONDITIONS  WHICH  OPPOSE  MALARIOUS  INFECTION. — Latitude  north 
of  63°  north,  and  south  of  57°  south,  is  usually  exempt  from  mala- 
ria, though  this  does  not  apply  to  the  Pacific  Coast,  where  the  Japan 
current  causes  a  much  higher  average  temperature,  far  north,  along 
the  coast,  than  usually  exists  outside  of  its  influence.  Altitude  is 
another  bar  to  its  invasion,  an  elevation  of  1,000  feet  being  usually 
exempt  from  its  influence,  though  mountainous  regions,  where  stag- 


220  SPECIFIC  INFECTIOUS  DISEASES. 

nant  water  is  evaporating,  under  the  average  temperature  essential 
to  its  development,  may  not  be  free  from  it.  It  has  been  proven 
that  the  use  of  boiled  loaler  for  potable  purposes  will  exempt  a  large 
majority  of  those  confining  themselves  to  it  during  malarial  epidem- 
ics, though  it  is  doubtless  true  that  the  infection  may  be  inhaled,  as 
well  as  taken  with  water.  Drainage  is  an  important  factor  in  the 
removal  of  malarious  elements  from  a  neighborhood.  Many  parts  of 
the  United  States  which  were  once  markedly  malarious,  are  now  tol- 
erably free  from  such  influence,  since  the  surface  has  been  provided 
with  proper  drainage  to  prevent  the  stagnation  of  water  upon  or 
near  the  surface.  Freezing  arrests  the  activity  of  malaria  germs, 
though  it  may  not  arrest  their  action  when  once  within  the  system. 
However,  malarious  diseases  begin  to  subside  as  soon  as  the  autum- 
nal frosts  appear,  and,  though  periodicity  may  be  an  element  in  win- 
ter diseases,  among  those  who  have  been  previously  affected,  no 
pronounced  malarious  attacks  occur  in  new  subjects  until  the  follow- 
ing spring.  Large  cities,  where  the  ground  is  thickly  set  with 
buildings,  and  the  streets  are  covered  with  pavements,  are  usually 
exempt  from  malaria.  But,  where  the  city  is  largely  one  of  residences, 
and  much  irrigation  of  lawns  goes  on  during  the  summer  months, 
as  in  California,  during  the  dry  season,  malaria  prevails  extensively. 
In  Oakland,  California,  where  there  are  so  many  large  lawns  under 
irrigation,  the  summer  months  are  marked  by  malarious  disturbances, 
though  few  outbreaks  of  ague  are  known,  probably  on  account 
of  the  modifying  influence  of  the  sea-breeze,  wafted  through  the 
Golden  Gate.  Marine  air  neutralizes  the  propagation  of  malarial 
germs  considerably.  A  long-continued  sea  voyage  is  nearly  a  cer- 
tain cure  for  malaria,  if  other  means  prove  futile. 

General  Pathology. — The  morbid  conditions  which  occur  in 
malaria,  arise  largely  from  the  destructive  action  of  the  parasites 
upon  the  red  blood-corpuscles;  for,  though  there  may  be  a  high 
fever  during  the  paroxysms,  the  tissue-changes  usually  due  to  pyrex- 
ial  action  are  not  so  marked  as  in  more  continued  fevers,  on  account 
of  the  periods  of  recuperation  afforded  here  by  the  intermissions  or 
remissions.  However,  in  pernicious  malarial  fevers,  the  extreme 
hyperpyrexia  may  lead  to  early  fatal  results. 

From  the  development  and  destructive  action  of  the  spores 
within  the  corpuscles,  we  have  a  large  amount  of  pigment  material 
(hemoglobin)  liberated,  which  becomes  distributed  through  the 
serum  and  tissues,  and  permanently  deposited  in  many  of  the  solid 
structures.  Even  in  mild  malarial  attacks,  permanent  pigmentation 
of  spots  in  the  skin  is  common,  due  to  the  deposit  of  hematoidin  in 
the  rete  mucosum;  and  internal  parts  are  found,  upon  post-mortem 


MALARIAL  FEVER.  221 

examination,  to  afford  evidence  of  a  similar  abnormal  staining. 
Thus  the  spleen,  liver,  kidneys,  peritoneum,  brain,  and  other  parts 
may  be  found  to  contain  deposits  of  this  pigmentary  material,  derived 
from  the  coloring  normally  held  in  the  red  corpuscles,  but  liberated 
by  the  destructive  action  of  the  hematozoa.  The  white  corpuscles 
also  become  loaded  with  this  material,  and  are  doubtless  instrumen- 
tal in  distributing  it  to  various  solid  structures.  The  extent  of  pig- 
mentation varies  with  the  duration  and  severity  of  the  disease;  acute 
attacks,  when  not  frequently  repeated,  may  not  leave  much  evidence 
of  this  character,  while  in  chronic  malarial  poisoning  (malarial 
cachexia)  the  staining  may  be  a  marked  feature. 

The  destruction  of  red  corpuscles  may  be  followed  by  two  classes 
of  results.  In  one  class,  we  find  disturbance  of  the  spleen  and  its 
associate  viscera,  and  in  the  other  those  which  attend  upon  impov- 
erishment of  the  blood  from  removal  of  red  corpuscles — anaemia  and 
hydrsemia. 

The  spleen,  being  intimately  associated  with  the  birth  of  red  blood- 
corpuscles  and  the  destruction  of  old  ones,  seems  remarkably  dis- 
turbed by  the  abnormal  destruction  which  goes  on  through  the  action 
of  the  malarial  parasite.  Simple  hyperaemia  probably  attends  at 
first,  especially  during  the  paroxysms,  and  now  there  is  little 
structural  chauge,  the  temporary  distention  probably  only  serving  to 
relax  and  debilitate  the  tissues  of  the  organ,  as  autopsies,  after 
death  from  pernicious  malarial  fever,  demonstrate  the  spleen  to  be 
swollen,  soft,  and  pulpy.  But  a  long-continued  and  oft-repeated 
influence  of  this  character  is  followed  by  structural  changes,  due, 
apparently,  to  chronic  inflammation,  as  there  is  abundant  evidence 
of  hyperplasia  from  extensive  proliferation  of  connective-tissue  cells. 
There  is  enormous  enlargement  of  the  organ,  and  its  tissues  are  firm 
and  resisting.  When  cut,  the  capsule  is  found  thickened,  and  the 
internal  structure  is  fibrous,  and  resisting  to  the  knife.  Rich  pig- 
mentary deposits  are  found  scattered  through  its  substance,  and, 
where  the  changes  have  gone  far  forward,  points  of  melanotic  deposit, 
or  amyloid  degeneration,  may  be  found  distributed  throughout  the 
organ.  The  liver,  and  other  organs  connected  with  the  portal  cir- 
culation, partake,  to  more  or  less  extent,  of  these  changes. 

The  loss  of  red  corpuscles  entails  a  condition  of  hydraemia  (the 
serum  being  tinged  a  more  or  less  pronounced  chocolate  color),  and 
general  impoverishment  of  the  blood  and  tissues.  The  tissues  are 
pallid  and  feeble,  the  circulation  being  impaired,  respiration  being 
hurried  upon  exertion,  and  palpitation  of  the  heart  arising  from 
slight  effort.  In  advanced  malarial  cachexia,  oedema  is  a  common 
condition  of  the  tissues,  and  effusion  into  the  serous  cavities  is  com- 


222  SPECIFIC  INFECTIOUS  DISEASES. 

monly  found  after  death.  The  poverty  of  the  blood  conduces  to 
various  degenerative  changes,  amyloid  degeneration  of  different  organs 
occurring  in  extreme  cases  of  malarial  cachexia.  When  death  occurs, 
it  is  usually  either  from  exhaustion,  or  hemorrhage. 

In  pernicious  malarial  fever,  the  ravages  of  the  hematozoa  are 
particularly  noticeable,  under  microscopical  examination.  The  red 
corpuscles  exhibit  the  presence  of  the  parasite  in  all  stages  of  devel- 
opment, with  the  corpuscles  in  every  stage  of  destruction.  The  arte- 
rioles  and  capillaries  of  the  brain  are  crowded,  in  some  places,  with 
parasites,  debris  of  broken-down  corpuscles,  and  pigmented  leuco- 
cytes. 

The  following  forms  of  malarial  fever  are  usually  described: 

INTEBMTTTENT  FEVEB. 

Synonyms. — Fever  and  Ague;  Chills  and  Fever;  Ague. 

Definition. — A  form  of  malarial  fever,  marked  by  separate  par- 
oxysms, each  consisting  of  a  chill  followed  by  fever  terminating  in  a 
sweating  stage,  with  a  distinct  intermission  (return  to  normal  tem- 
perature )  before  the  following  paroxysm. 

Etiology. — Intermittent  fever  is  one  of  the  phases  of  malarial 
disease,  and  is  a  common  form  resulting  from  malarial  infection. 
Whatever  tends  to  depress  the  physical  or  mental  powers,  lessens 
the  ability  of  the  individual  to  resist  the  invasion  of  the  infection, 
and  delicate  and  debilitated  persons  are  usually  first  to  be  affected, 
when  a  community  is  invaded  by  the  morbid  influence.  Intemper- 
ance, exposure  to  the  night  air,  overwork,  exposure  to  chilling 
draughts  of  air  and  other  vicissitudes,  are  among  the  predisposing 
causes. 

Pathology. — The  lesions  of  this  disease  are  not  very  marked, 
and  are  confined  almost  entirely  to  congestion  of  the  internal  organs. 
The  spleen  and  liver  are  nearly  always  enlarged  to  a  greater  or  less 
degree,  but  this  enlargement  is  the  result  of  simple  hyperamia, 
instead  of  structural  change.  These  only  appear  after  the  parox- 
ysms have  been  often  repeated — after  the  malarial  poison  had  been 
influencing  the  system  for  a  long  time.  Other  internal  organs,  nota- 
bly the  kidneys  and  mucous  membrane  of  the  intestines,  are  involved 
in  the  hyperaemic  condition,  though  not  to  so  great  an  extent  as  the 
liver  and  spleen. 

The  blood  changes  are  not  so  marked  as  in  typhoid,  typhus,  and 
some  other  forms  of  infectious  fever.  It  clots  imperfectly,  however, 
and  is  abnormally  dark  in  color.  Diminution  of  the  fibrin-elements 
and  red  corpuscles  occurs  when  the  disease  continues  long,  and  dur- 


MALARIAL  FEVER:   INTERMITTENT  FORM.  223 

ing  a  paroxysm  there  is  a  notable  increase  in  the  number  of  white 
corpuscles. 

Symptoms. — These  will  depend  upon  the  type  which  the  dis- 
ease assumes.  In  the  quotidian  type,  a  chill  occurs  every  twenty- 
four  hours,  in  the  tertian  type  every  forty-eight  hours,  in  the  quar- 
tan type  every  seventy-two  hours.  Many  cases  tend  to  recur  every 
seven  days,  and  this  tendency  should  be  borne  in  mind  during  treat- 
ment, that  provision  be  made  for  it.  These  types  may  occur  in 
double  form,  two  paroxysms  occurring  daily  in  double  quotidian, 
one  every  day  in  double  tertian,  but  at  a  different  hour  on  every 
alternate  day,  the  paroxysms  also  differing  in  character,  being 
marked  by  severe  chill  and  light  fever  one  day  and  light  chill  and 
severe  fever  another,  or  varying  in  some  other  particular. 

The  paroxysms  are  marked  by  three  stages :  a  cold  stage  or  chill ; 
a  hot  stage,  or  the  stage  of  fastigium;  and  a  stage  of  decline,  or  the 
sweating  stage. 

The  cold  stage  is  characterized  by  a  pronounced  rigor;  the 
subject  shakes,  from  head  to  foot.  Cold  sensations  first  creep  along 
the  spine,  but  later  pervade  the  entire  body.  The  finger-tips  and 
nose  become  blue,  the  skin  shriveled,  and  covered  with  prominent 
papillae  (cutis  anserina);  the  face  becomes  pale,  the  eyes  sunken  and 
anxious,  and  the  voice  faint  and  husky.  The  sufferer  becomes  weak 
;ind  tremulous,  and,  as  the  chill  continues,  he  shakes  and  shivers 
convulsively,  and  his  teeth  chatter.  The  respirations  are  now  short 
and  sighing;  the  surface  of  the  body  is  cold  to  the  touch;  micturition 
is  frequent,  the  urine  being  pale  and  limpid.  After  half  an  hour 
or  more  these  symptoms  gradually  subside ;  the  patient  no  longer 
complains  of  being  chilly,  and  becomes  more  comfortable. 

But  he  soon  realizes  that  a  sense  of  warmth  is  rapidly  pervading 
his  body,  and  finds  that  the  warmth  is  more  than  that  of  comfort; 
the  skin  becomes  dry  and  hot,  the  face  flushed,  the  eyes  suffused  and 
bright;  the  pulse  bounds,  the  carotids  throb;  the  tongue  is  dry,  and 
there  is  intense  thirst,  and  often  vomiting.  These  symptoms  con- 
tinue to  increase  in  severity  until  the  patient  is  extremely  restless 
and  uncomfortable,  the  paroxysms  often  being  attended  by  excruci- 
ating muscular  pain,  this  frequently  involving  the  pericranial  mus- 
cles. During  a  quotidian  ague,  the  hot  stage  may  continue  for  eight 
or  ten  hours,  and  that  of  a  quartan  four  or  six,  though  in  any  case 
it  may  terminate  in  oue  or  two  hours. 

There  is  hardly  any  state  where  the  febrile  symptoms  are  more 
marked  for  a  short  time  than  in  this  disease.  Though  the  teir\pera- 
ture  may  rise  to  104°  F.  during  the  chill,  it  may  reach  107°  during 
the  hot  stage.  There  is  marked  arrest  of  secretion,  the  urine  is 


224 


SPECIFIC  INFECTIOUS  DISEASES. 


scanty  —  almost  suppressed  —  and  high  colored.  The  skin  and  mouth 
are  dry,  there  is  intense  thirst,  the  breath  is  hot,  and  the  bowels 
are  constipated.  Severe  headache  and  restlessness  often  mark  this 
period.  In  children,  convulsions  and  coma  are  not  rare. 

As  the  sweating  stage  approaches,  a  moisture  appears  on  the  fore- 
head, and  soon  covers  the  entire  surface  of  the  body.     Restlessness 

and  discomfort  rapidly  abate.  The 
temperature  falls  speedily,  pain  and 
headache  subside,  a  free  perspiration 
bathes  the  surface,  the  urine  flows 
copiously,  thirst  disappears,  and  the 
patient  seems  as  well  as  common. 
An  interval  now  occurs,  correspond- 
ing to  the  type  of  the  fever,  after 
•which  another  paroxysm  is  ushered 
in  with  a  chill,  and  a  repetition  of 
the  symptoms  of  the  three  stages  is 
again  gone  through. 

Badly  treated,  and  neglected 
cases  of  this  disease  continue  to 
present  a  recurrence  of  the  parox- 
ysms, and,  after  a  time,  the  regular- 
ity of  the  disease  may  become  dis- 
turbed, the  attacks  occurring 
erratically,  the  general  health  of  the 
subject  becoming  much  deranged, 
the  stomach  becoming  foul,  the  tongue  coated  with  a  pasty  wliito 
coating,  the  liver  and  spleen  becoming  enlarged,  and  a  complication 
of  jaundice  and  anaemia  being  strikingly  manifested.  Such  cases 
constitute  chronic  intermittents  (malarial  cachexia),  and  demand 
careful  and  discriminating  treatment,  even  for  the  arrest  of  the  par- 
oxysms, as  ordinary  remedies  are  quite  likely  to  fail  in  controlling 
them. 

Diagnosis.  —  The  diagnosis  of  intermittent  fever  is  very  simple. 
We  distinguish  it  from  remittent  fever  by  the  fact  that  there  is  a 
complete  intermission  between  the  paroxysms,  the  following  attack 
being  ushered  in  with  a  chill,  while  there  is  not  a  complete  inter- 
mission in  remittent  fever,  there  being  but  the  initiatory  chill,  usu- 
ally, and  only  a  near  approach  to  normal  temperature  between  the 
exacerbations  of  fever  which  follow.  There  is  hardly  a  chance  that 
intermittent  fever  will  be  confounded  with  pyaemia,  as  in  this  dis- 
ease the  chills  occur  irregularly,  and  the  history  of  the  cases  will 
disclose  a  different  class  of  etiological  factors,  in  each  instance. 


NTERMITTENT. 


MALARIAL  FEVER  :   INTERMITTENT  FORM. 


225 


Treatment. — That  class  of  practitioners  who  regard  quinine 
and  arsenic  as  specifics  for  ague,  are  usually  unsuccessful  in  its  man- 
agament.  Whittaker  asserts  that  the  hematozoa  disappear  from 
the  blood  after  the  administration  of  quinia,  and  assumes  that  the 
specific  for  the  disease  is  this  drug=  Depend  upon  it,  they  who  fol- 
fow  such  teaching  will  leave  but  sorry  results  behind,  and  their 
patients  will  finally  be  obliged  to  remove  from  the  country  or  employ 
other  physicians.  If  they  arrest  the  paroxysms  of  an  ague,  which 
they  will,  in  many  cases,  there  will  usually  be  relapse  after  relapse, 
until  malarial  cachexia  will  finally  be  established.  Quinia  hardly 
ever  cures  ague,  though  it  is  our  best  antiperiodic — the  best  agent 
to  interrupt  the  paroxysms.  Arsenic  is  more  permanent  in  its  action, 
but  it  should  not  be  depended  upon  alone  to  perfect  a  cure  in  as 
stubborn  a  disease  as  intermittent  fever. 


JCL 


\ 


QUOTIDIAN  INTEBMITTEN-T. 


QUABXAX  lyTERMTTTEXT. 


Probably  it  will  be  best  to  consider  the  treatment  of  the  stages 
separately.  The  management  of  the  cold  stage  may  do  much  to  deter- 
mine the  severity  of  the  remaining  portion  of  the  paroxysm.  If  a 
patient  be  placed  in  an  alcoholic  vapor  bath  or  a  steam  bath  at  the 
beginning  of  the  chill,  the  paroxvsm  may  often  be  almost  entirely 
aborted,  the  chill  quickly  passing  off,  and  the  hot  stage  being  com- 
pletely averted.  The  use  of  a  hot  pack,  the  patient  being  wrapped 
in  a  blanket  wrung  out  of  hot  water,  hot  irons  or  hot  ears  of  corn 
being  placed  around  him  to  assist  in  maintaining  the  warmth,  if  nec- 

16 


226  SPECIFIC  INFECTIOUS  DISEASES. 

essary,  will  answer  the  same  purpose,  as  will  any  other  external 
appliance  which  will  determine  a  rapid  flow  of  blood  to  the  surface. 
In  this  way,  the  severe  congestion  of  the  internal  organs,  sure  to 
attend  the  ordinary  course  of  the  disease,  is  prevented,  and  the  reac- 
tion necessarily  following,  is  averted.  Those  who  desire  to  succeed 
in  such  cases  can  instruct  fhe  nurse  in  the  administration  of  this 
treatment,  and  when  the  physician  arrives,  his  task  will  be  simpli- 
fied. When  the  physician  is  at  hand,  he  may  find  considerable  sat- 
isfaction in  the  use  of  nitrite  of  amyl,  by  inhalation,  in  this  stage, 
from  three  to  five  drops  being  thus  administered. 

During  the  hot  stage,  the  administration  of  the  special  sedatives, 
properly  selected  and  adapted,  is  to  be  commended.  Gelsemium  is 
an  excellent  agent,  as  it  controls  the  determination  to  the  brain  so 
commonly  attending,  and  lessens  the  height  of  the  fever,  by  promot- 
ing secretion  from  the  skin,  lungs,  and  kidneys.  Jaborandi  is  also 
excellent,  though  it  should  not  be  administered  in  too  large  doses. 
Two  or  three  drops  of  gelsemium  or  ten  of  jaborandi  may  be  admin- 
istered every  hour  during  this  stage,  in  ordinary  cases.  But  gastric 
irritation  may  be  present,  and  neither  of  these  remedies  will  then  be 
appropriate.  Here  a  combination  of  aconite  and  rhus  tox.  will  be 
demanded,  as  the  sedative  action  is  admirable,  while  the  gastric  irri- 
tability is  nicely  controlled  by  this  prescription.  Add  fifteen  or 
twenty  drops  of  rhus  and  five  or  ten  of  aconite  to  four  ounces  of 
water,  and  give  a  teaspoonful  every  half-hour.  Such  measures  will 
shorten  the  length  of  the  hot  stage,  thus  hastening  the  advent  of  the 
stage  of  decline,  and  will,  moreover,  prepare  the  way  for  the  ready 
appropriation  of  the  antiperiodic,  which  it  will  be  necessary  to 
administer  during  the  intermission.  f 

The  sweating  stage  brings  its  own  relief,  and  demands  no  especial 
treatment,  though  the  patient  should  guard  against  chilling,  while 
relaxed. 

An  important  measure  now  is  to  interrupt  the  periodicity  of  the 
disease  and  prevent,  if  possible,  a  recurrence  of  the  paroxysm.  If 
the  hot  stage  has  lasted  eight  or  ten  hours,  we  are  pretty  sure  that 
there  will  be  a  chiU  on  the  following  day  at  about  the  same  hour  as 
on  that  of  the  first  attack,  and  we  will  prepare  to  meet  it  by  fortify- 
ing the  nervous  system  with  a  powerful  and  appropriate  stimulant. 
Our  first  choice  will  be  the  sulphate  of  quinia,  though  we  prefer  not  to 
produce  too  profound  cinchonism,  since  this  is  liable  to  leave 
unpleasant,  if  not  permanent,  effects  behind,  such  as  tinnitus  aurium, 
deafness,  etc.  Our  sedative  has  prepared  the  patient  for  this  remedy, 
however,  so  that  the  small  dose  will  suffice.  We  will  begin  seven 
or  eight  hours  before  the  time  of  the  expected  chill,  and  administer 


MALARIAL  FEVER:   INTERMITTENT  FORM.  227 

three  three-grain  doses  of  quinia  sulphas,  in  capsules,  one  every 
two  hours.  This  will  give  us  an  advantage  over  the  single  dose, 
should  the  ague  prove  "anticipating,"  and  should  it  prove  "defer- 
ring" the  plan  will  hardly  be  less  effective  than  the  administration 
of  the  single  dose.  If  everything  is  in  good  condition  for  the  recep- 
tion of  the  quinine,  we  may  expect  that  the  chill  will  not  occur. 
For  fear  that  we  may  have  a  tertian,  instead  of  a  quotidian,  it  may 
now  be  well  to  continue  the  sedative  in  minute  doses  for  the  next 
day,  and  repeat  the  quinine  as  on  the  day  previous.  If,  instead  of 
complete  success  the  first  day  of  treatment,  we  are  disappointed  in 
finding  the  chill  to  reappear  on  the  second  or  third,  in  spite  of  the 
antiperiodic,  we  will  repeat  it  the  following  time,  when  success  will 
be  almost  certain  to  be  the  result. 

It  is  good  practice  to  continue  the  use  of  the  sedative  through- 
out the  period  of  treatment.  By  this  means,  the  system  is  prepared 
for  the  kindly  acceptance  and  effective  action  of  the  antiperiodic,  a 
cure  being  speedy  and  certain.  In  order  that  quinine  may  be 
received  kindly  by  the  stomach,  and  readily  absorbed,  and  its  action 
be  unattended  by  unpleasant  nervous  symptoms,  the  skin  and 
tongue  should  be  moist,  and  the  pulse  should  be  open  and  soft. 
This  condition  is  to  be  brought  about  by  the  action  of  properly 
selected  sedatives.  Gelsemium,  being  anti-malarial  in  its  properties, 
as  well  as  sedative,  is  an  ideal  sedative  in  malaria,  unless  clearly 
contraiudicated  by  the  oppressed,  feeble  pulse  and  cold  extremities. 
In  this  case  we  will  use  belladonna  instead.  Use  these  remedies  as 
follows :  R  Green  plant  tincture  or  specific  medicine  gelsemium  gtt. 
xx,  water  fiv.  M.  Dose,  a  teaspoonful  every  hour.  B  Specific 
medicine  belladonna  gtt.  iii— v,  water  fiv.  M.  Dose,  a  teaspoonful 
every  hour.  Aconite  combines  well  with  both  remedies,  and  assists 
their  action.  Ten  drops  of  Lloyd's  aconite  may  be  added  to  either 
prescription,  for  an  adult. 

Having  arrested  the  paroxysms,  the  next  measure  is  to  place  the 
system  in  such  condition  that  there  will  not  be  a  return  of  the  chills 
and  fever  within  a  few  days  afterward.  In  order  to  fortify  the  nerv- 
ous system  against  probability  of  this  recurrence,  I  think  highly  of 
the  third  decimal  trituration  of  arseniate  of  quinia.  This  should  con- 
stitute a  regular  medicine  for  a  month,  two  or  three  grains  being  given 
thrice  daily,  before  meals.  The  activity  of  the  portal  circulation 
should  be  looked  after,  as  the  congestion  resulting  here  from  the 
agu^  has  most  assuredly  left  a  sluggish  capillary  action,  and  impaired 
function.  The  following  prescription  will  be  of  service  here,  to  be 
administered  after  meals,  three  times  daily:  B  Polymnia  fi,  chio- 
nanthus  vir.  fi  M.  Ten  to  fifteen  drops,  in  water.  Keep  a  watch 


228  SPECIFIC  INFECTIOUS  DISEASES. 

on  the  seventh,  fourteenth,  twenty-first,  and  twenty-eighth  days. 
On  these  days  administer  a  three-grain  capsule  of  quinine  with  the 
arseniate  of  quinia,  before  each  meal.  After  the  twenty-eighth  day 
the  disease  may  be  considered  cured,  provided  there  has  been  no 
paroxysm  in  the  meantime.  If  there  has,  there  should  be  a  period 
of  complete  immunity  assured,  for  four  weeks  after  the  last  paroxysm. 

MASKED  INTERMITTENTS. — Periodical  manifestations  often  occur  in 
malarious  districts,  which  evidently  result  from  malarious  influence, 
and  require  a  similar  treatment  to  that  employed  in  intermittent 
fever;  at  least  the  periodical  phase  of  such  cases  demands  the  treat- 
ment applied  to  the  periodicity  of  intermitteuts.  Beyond  this  we 
need  to  apply  the  special  treatment  required  by  the  characteristics 
of  each  particular  case. 

Undoubtedly,  the  etiological  factor  here  is  identical  with  that  of 
intermittent  fever,  the  disease  manifesting  more  of  a  local  predilection. 

Supraorbital  pain,  of  intensely  painful  character,  appearing  in 
the  forepart  of  the  day  and  continuing  until  evening,  to  pass  off  and 
reappear  on  the  following  day,  at  about  the  same  hour,  and  to  recur 
day  after  day,  is  a  common  manifestation  of  this  kind.  Occipital 
pain  is  another  form  of  neuralgia  which  appears  periodically,  and 
may  be  due  to  malaria.  Severe  abdominal  colic,  appearing  at  some 
time  in  the  day  or  night,  continuing  for  several  hours  and  then  sub- 
siding, to  return  the  following  day  or  upon  the  second  day,  is  another 
form  of  masked  ague.  Periodical  sciatica,  intercostal  or  frontal  pain, 
tic  douloureux,  periodical  attacks  of  croup,  asthma,  diarrhoea,  dysen- 
tery, hematuria,  torticollis,  etc.,  have  been  observed  as  periodical 
manifestations  of  malarious  infection,  and  relieved  mainly  by  the 
employment  of  antiperiodics. 

Many  times  malarious  influence  complicates  other  diseases  and 
renders  them  stubborn  to  treatment,  until  the  malarial  element  has 
been  recognized  and  met.  This  assertion  applies  to  almost  every 
form  of  acute  disease,  and  it  should  be  suspected  wherever  marked 
periodicity  is  manifested  persistently.  Here  an  antiperiodic  should 
be  exhibited  at  an  early  period  in  the  treatment. 

Periodical  muscular  pain  will  demand  quinine  and  cimicifuga. 
Periodical  tic  douloureux  will  demand  quinine  and  piper  methysti- 
cum.  Periodical  pain  in  the  middle  ear  will  demand  quinine  and 
pulsatilla.  Periodical  dysentery  will  demand  quinine  and  ipecac. 
Periodical  croup  will  demand  quinine  and  aconite,  etc.  In  each 
case,  the  antiperiodic  should  anticipate  the  paroxysmal  attack  in  the 
same  manner  as  in  the  treatment  of  that  of  intermittent  fever.  In 
case  a  chronic  condition  of  the  kind  becomes  established,  the  treat- 
ment applicable  to  chronic  intermittents  will  be  applicable  here. 


MALARIAL  FEVER:    REMITTENT  FORM.  229 

REMITTENT  FEVER. 

Synonyms. — Bilious  Eemittent  Fever;  Jungle  Fever. 

Definition. — A  form  of  malarial  fever  in  which  the  temperature 
remits,  but  does  not  intermit,  and  the  exacerbations  are  diurnal  in 
character,  invariably. 

Etiology. — This  form  of  malarial  fever  is  most  liable  to  occur 
in  marshy  districts,,  the  malarial  poisoning  being  intense  in  quality, 
or  else  the  patient  manifesting  a  marked  susceptibility.  It  is 
undoubtedly  due  to  the  same  character  of  poison  as  the  infection 
of  intermittent  fever,  one  form  frequently  merging  into  the  other, 
when  neglected  or  badly  treated.  Remittent  fever  is  believed  to  be 
a  manifestation  of  a  more  severe  grade  of  malarial  infection  than 
intermittent  fever,  and  in  severe  cases  it  is  not  uncommon  for  a 
remittent  fever  to  become  an  intermittent,  during  convalescence. 
The  severity  of  this  disease  is  determined  largely  by  climate,  that 
which  occurs  in  temperate  regions  being  mild  and  tractable  when 
compared  with  that  which  occurs  in  the  tropics. 

Pathology. — The  pathology  of  remittent  fever  is  almost  iden- 
tical with  that  of  intermittent,  the  difference  being  that  of  degree 
instead  of  kind.  The  cause  being  the  same,  we  could  hardly  expect 
much  difference,  though  the  more  continuous  febrile  action  would 
naturally  result  in  greater  tendency  to  pathological  changes.  Dimi- 
nution of  red  globules  and  loss  of  fibrin  in  the  blood  is  common  to 
both  forms.  Free  pigment-granules,  however,  are  more  abundant 
in  remittent  fever  than  in  intermittent  They  are  seldom  present  in 
intermittent,  except  in  the  pernicious  forms,  while  they  are  almost 
constantly  present  in  all  forms  of  remittent.  This  pigment  is  due  to 
particles  of  hemaglobin,  liberated  from  the  corpuscles  and  floating 
free  in  the  plasma,  it  being  transformed  into  granular  or  crystalline 
hematoidin. 

The  spleen  is  enlarged,  but  not  so  markedly  as  in  intermittents, 
suggesting  that  the  splenic  congestion  may  be  more  the  result  of  the 
cold  than  of  the  hot  stage.  Pigmentation  is  here  a  marked  feature 
of  the  pathological  condition,  and  the  congested  tissues  are  dark 
and  friable  in  advanced  stages  of  severe  cases.  The  liver  presents  a 
peculiar  appearance,  though  there  is  not  remarkable  congestion;  the 
peculiarity  is  the  color,  the  organ  presenting  a  bronzed  hue,  through- 
out its  substance,  the  "bronzed  liver"  being  regarded  as  character- 
istic of  this  disease.  However,  it  is  occasionally,  though  rarely, 
met  with  in  intermittent  and  pernicious  fever. 

Changes  occur  in  the  mucous  membrane  of  the  alimentary  canal. 
The  mucous  membrane  of  the  stomach  and  small  intestines  is  con- 
gested and  softened,  and  the  glandular  structures  are  enlarged. 


230 


SPECIFIC  INFECTIOUS  DISEASES. 


There  may  be  ulceration  in  places,  though  not  of  the  character  of 
that  of  typhoid  fever. 

Symptoms. — There  is  usually  an  intimation  of  the  approach  of 
this  disease  manifested  by  a  sense  of  oppression  in  the  epigastrium, 
with  headache  and  general  malaise,  for  two  or  three  days  before  the 
chill  occurs.  The  tongue  often  accumulates  a  pasty-white  coating, 
and  the  appetite  disappears,  during  this  time.  Though  marked,  the 
chiR  is  not  as  protracted  as  that  of  intermittent  fever,  and  there  is 
not  the  tremulousness  and  shaking,  chattering  of  the  teeth,  etc., 
which  occurs  in  ague ;  and  the  sensation  of  coldness  is  general  in  its 
inception,  not  coming  on  by  creeping  along  the  spine  in  the  begin- 
ning, as  in  intermittents.  Symptoms  of  nausea  may  be  manifest 
even  during  the  chill,  but  if  not,  they  are  apt  to  appear  soon  after 
the  hot  stage  begins.  Thirst  is  almost  always  an  urgent  symptom. 


Jlf. 


tc 


- 


REMITTENT  FEVER. 


The  temperature  may  advance  two  or  three  degrees  during  the 
chill,  but  it  rises  rapidly  after  the  hot  stage  begins,  and  within  ten 
or  twelve  hours  after  its  inception  the  thermometer  may  mark  105°  or 
106°  R  The  skin  becomes  dry  and  hot,  the  pulse  increases  in  fre- 
quency, ranging  from  100  to  120  per  minute,  being  full  and  bounding 
in  individuals  of  fair  reactive  power.  The  face  is  flushed,  the  eyes 
suffused,  the  conjunctiva  congested,  and  the  patient  is  restless  and 
uneasy.  Muscular  pain  is  now  a  common  symptom,  there  being  ach- 
ing in  the  back  and  limbs,  in  many  cases,  or  severe  hemicrania;  in 
many  cases  there  is  full,  throbbing  headache.  As  the  headache  con- 
tinues, the  gastric  symptoms  are  apt  to  become  aggravated,  the  nau- 
sea and  vomiting  being  one  of  the  most  unpleasant  features  of  the 
case,  though  this  symptom  is  not  invariably  present.  Epigastric 
pain  is  a  very  distressing  symptom,  in  many  of  the  cases  in  which 


MALARIAL  FEVER:    REMITTENT  FORM.  231 

vomiting  is  present,  and  this  is  aggravated  instead  of  relieved  by 
vomiting.  The  material  ejected  by  vomiting  becomes  greenish  as 
soon  as  the  contents  of  the  stomach  have  been  evacuated,  this  "bil- 
ious" material  having  given  the  name  "bilious  fever"  to  the  disease, 
in  many  quarters.  Constipation  of  the  bowels  is  a  common  symp- 
tom; though,  if  it  be  not  arrested  by  treatment,  diarrhoea  sets  in 
later. 

After  ten  or  twelve  hours,  a  slight  perspiration  appears  on  the 
forehead  and  gradually  extends  over  the  body,  while  many  of  the 
unpleasant  symptoms  disappear.  The  gastric  symptoms  now  become 
ameliorated,  the  restlessness  and  headache  subside,  the  temperature 
falls  several  degrees,  and  the  patient  experiences  a  number  of  hours 
of  comparative  comfort — surcease  from  the  sufferings  of  the  hot 
stage.  But  the  hot  stage  does  not  entirely  disappear.  The  ther- 
mometer will  indicate  a  temperature  above  normal  during  the  most 
comfortable  period,  and,  on  the  following  day,  the  fever  will  return, 
and  all  the  discomforts  and  suffering  of  the  preceding  day  will  be 
repeated,  with  aggravation  of  many  of  the  most  important  ones, 
unless  proper  treatment  has  been  promptly  begun.  The  increase  of 
fever,  with  the  attending  symptoms,  is  termed  the  exacerbation;  the 
decline  of  the  fever  and  attendant  symptoms,  the  remission. 

It  will  be  noticed,  however,  that  the  decline  of  the  fever — the 
interval  between  the  exacerbations — is  not  followed  by  a  chill  before 
the  following  rise  of  temperature  occurs.  There  is  a  regular  rising 
and  falling  of  the  fever,  day  after  day,  with  but  the  one  chill — that 
which  initiated  the  attack.  This  fact  will  distil  guish  the  disease 
from  ague. 

Not  all  cases  of  this  fever  are  so  severe  as  the  symptoms  here 
given  might  indicate.  Often  the  symptoms  are  much  more  mild,  and 
the  disease  occurs  without  the  manifestation  of  severe  gastric  dis- 
turbance. Again,  proper  treatment,  begun  early,  will  often  mask  the 
full  development  of  the  case.  Sometimes  the  febrile  symptoms  are 
not  marked,  the  temperature  of  the  exacerbation  not  reaching  more 
than  103°,  the  corresponding  symptoms  being  much  modified.  Here, 
however,  there  will  likely  be  considerable  nervous  prostration,  with 
gastric  irritability,  attended  by  nausea,  insomnia,  anorexia,  irritable 
stomach,  indicated  by  pointed  tongue,  with  reddened  tip  and  edges, 
small,  wiry  pulse,  and  idiosyncrasy  against  the  kindly  reception  of 
quinine  as  an  antiperiodic.  Such  patients  are  usually  delicately 
organized,  and  require  an  entirely  different  course  of  treatment  from 
that  which  is  applicable  to  the  more  sthenic  cases. 

Diagnosis. — The  diagnosis  of  malarial  remittent  fever  is  not 
difficult,  though  it  would  be  if  the  temperature  curve  were  to  be 


232  SPECIFIC  INFECTIOUS  DISEASES. 

depended  upon  alone — unless  a  microscopical  examination  of  the 
blood  were  made  to  detect  the  plasmodium  malarise.  The  remis- 
sions are  not  only  shown  by  the  thermometer,  but  there  is  a  clinical 
picture  of  relief  afforded  during  the  remission,  not  observable  in 
remittents  of  non-malarious  origin.  After  the  use  of  sedatives  for  a 
short  time,  the  reception  of  quinine  is  kindly  and  its  action  effective, 
while  this  is  not  the  case  in  other  remittents.  The  vomiting  and 
bilious  symptoms  are  present  in  yellow  fever,  but  here  there  is  but 
the  one  paroxysm,  and  its  contagious  character  is  soon  developed. 
The  single  chill  in  the  beginning  will  differentiate  it  from  intermit- 
tent fever,  which  is  characterized  by  a  succession  of  rigors. 

Prognosis. — Simple  remittent  fever,  of  malarial  origin,  is  not  a 
grave  disease,  under  proper  treatment.  It  hardly  ever  proves  fatal, 
though  often  prolonged  and  aggravated  by  improper  management. 
Ordinary  cases  ought  to  be  convalescent  within  four  or  six  days. 

Treatment. — Simple  cases  of  remittent  fever,  in  temperata 
regions,  are  usually  readily  arrested  within  the  first  week.  Quinine 
is  the  remedy  which  arrests  the  paroxysms,  it  only  being  necessary 
to  prepare  the  patient  for  its  ready  appropriation.  With  secretion 
arrested,  absorption  by  the  stomach  is  impaired,  and  a  stimulant  to 
the  nervous  centers,  like  quinia,  when  absorbed,  acts  as  an  irritant, 
instead  of  promoting  normal  functional  action.  The  administration 
of  the  antiperiodic,  then,  without  first  preparing  the  patient  for  it, 
produces  unpleasant  effects,  and  does  not  yield  as  good  results  as 
when  the  way  is  properly  paved  for  its  use.  A  properly  selected 
sedative,  then,  is  the  first  desideratum,  and  this  should  be  adminis- 
tered in  small  doses,  frequently  repeated,  throughout  the  course  of 
the  disease.  It  is  hardly  necessary  to  enter  into  details  as  to  the 
proper  sedative  to  be  selected.  Gelsemium  will  be  recollected  as  the 
ideal  sedative  where  there  is  the  full,  bounding  pulse,  with  bright  eyes, 
contracted  pupils,  flushed  face,  etc.  Jaborandi  will,  however,  often 
afford  better  satisfaction  in  these  cases.  The  specific  medicine  will 
hardly  fail  to  accomplish  good  work  here. 

The  gastric  complication  which  attends  many  cases  will,  how- 
ever, modify  this  selection,  the  condition  demanding  a  remedy  which 
will  serve  the  double  purpose  of  a  general,  as  well  as  gastric,  seda- 
tive. Aconite  is  here  the  leading  remedy  as  a  sedative,  while  rhus 
tox.  combines  well  with  it,  as  it  is  one  of  the  most  reliable  gastric 
sedatives  we  possess,  the  same  property  belonging,  in  not  a  little 
degree,  to  aconite. 

The  size  of  the  dose  to  be  employed  in  these  cases  is  an  impor- 
tant consideration.  Too  much  of  a  sedative  action  would  ba  likely 
to  embarrass  instead  of  assisting  the  cure,  and  too  little  would  only 


MALARIAL  FEVER:   REMITTENT  FORM.  233 

be  temporizing.  The  ability  of  the  stomach  to  tolerate  the  medicine 
should  also  be  considered.  Two  drachms  of  specific  jaborandi  (or 
some  other  reliable  preparation)  should  be  added  to  four  ounces  of 
water,  and  a  teaspoonful  ordered  every  hour.  Where  gelsemium_is 
employed,  the  dose  may  vary  from  one-half  drop  to  two  drops, 
repeated  every  hour.  In  using  the  aconite  and  rhus  combined,  from 
five  to  ten  drops  of  aconite  and  fifteen  or  twenty  drops  of  rhus  in 
four  ounces  of  water,  will  meet  the  requirements,  the  dose  being  a 
teaspoonful  every  hour,  as  with  the  other  remedies  named. 

Muscular  pains  should  not  be  neglected,  as  they  are  common  com- 
plications (or  conditions)  of  this  disease.  Often  we  may  be  able  to 
combine  cimicifuga  or  rhamnus  californica  with  the  sedative  mixture, 
and  arrest  this  at  an  early  period  of  treatment.  Where  it  is  stub- 
born, a  decoction  of  rhamnus  should  be  given  separately,  in  full 
doses,  until  a  laxative  effect  is  produced;  or,  in  the  absence  of  the 
bark,  a  good  fluid  preparation  may  be  administered  in  fifteen-  or 
twenty-drop  doses,  until  the  same  object  is  attained.  In  many  cases 
I  have  been  well  pleased  with  the  action  of  a  combination  of  phenace- 
tin  and  arseniate  of  quinia.  I  employ  it  in  capsules,  each  containing 
three  grains  of  phenacetin  and  two  of  arseniate  of  quiuia,  the  capsule 
being  administered  every  three  hours,  until  the  object, — the  relief  of 
the  myalgia, — has  been  accomplished.  However,  the  remedies  for 
pain  should  not  interfere  with  the  steady  use  of  the  appropriate 
sedative. 

During  the  remission  is  the  proper  time  for  the  administration 
of  the  antiperiodic.  This  will  ordinarily  be  quinine,  and  it  will  usu- 
ally act  promptly  and  effectively,  as  well  as  kindly,  in  interrupting 
the  exacerbations  and  subduing  the  disease,  when  the  tongue  is  moist 
and  cleaning,  and  the  pulse  full  and  soft.  We  need  not  wait  for 
decided  evidence  of  this  condition  after  the  sedative  has  been  admin- 
istered for  twenty-four  hours,  for  this  will  almost  certainly  insure 
the  kindly  appropriation  of  the  quinine.  Three  grains  of  this  rem- 
edy, in  capsule,  may  be  administered  as  soon  as  the  remission 
beccmea  well  marked,  and  repeated  every  hour  until  three  doses 
have  been  taken,  or  until  a  marked  rise  in  temperature  is  manifested. 
The  exacerbation  now  being  again  initiated,  the  antiperiodic  should 
be  withdrawn  until  the  next  remission,  when  it  should  be  repeated 
as  before.  While  the  antiperiodic  is  being  administered,  the  seda- 
tive may  be  continued,  as  well  as  during  the  exacerbations,  through- 
out the  course  of  the  disease. 

There  are  certain  septic  conditions  which  may  interfere  with  the 
kindly  appropriation  of  the  antiperiodic,  at  least  with  its  curative 
effect,  and  these  should  not  be  forgotten,  as  they  are  rather  common 


234  SPECIFIC  INFECTIOUS  DISEASES. 

in  remittent  fever.  The  most  important  condition  of  this  character, 
as  it  is  the  common  one,  is  that  marked  by  the  pasty  white  coating 
on  the  tongue,  suggesting  excessive  acidity  of  the  gastro-intestinal 
canal.  Such  a  condition  will  demand  the  administration  of  sulphite 
of  sodium,  which  may  be  given  in  capsules,  from  half  a  grain  to  a 
grain  at  a  time,  repeated  every  three  hours,  until  the  toDgue  has 
begun  to  clean.  This  must  be  a  cardinal  feature  of  the  treatment 
when  the  indication  for  it  is  well  marked,  if  success  is  to  be  expected. 
The  proper  action  of  all  other  medicine  will  depend  upon  this  meas- 
ure. Sometimes  an  emetic  will  be  demanded  as  an  initiatory  meas- 
ure of  the  treatment.  Here  the  tongue  will  be  heavily  loaded  at  the 
base,  there  will  be  gaseous  eructations,  and  other  evidences  of  chy- 
lopoietic  torpor.  In  order  to  insure  proper  results  here,  the  patient 
should  have  a  thorough  emetic,  and  it  may  be  necessary  to  repeat  it 
on  the  following  day.  A  yellow-coated  tongue  suggests  a  cathartic. 
The  treatment  of  the  nervous  form  of  remittent  fever  requires  the 
use  of  aconite  and  rhus  tox.  as  a  sedative.  The  gastric  irritability, 
indicated  by  the  pointed  tongue,  with  reddened  tip  and  edges, 
demands  this  treatment,  and  the  nervous  irritability,  restlessness, 
nocturnal  delirium  (which  occasionally  attends),  and  small,  rapid 
pulse,  all  suggest  this  sedative.  As  the  remissions  are  not  marked, 
and  as  quinine  does  not  seem  to  act  well  in  interrupting  the  fever, 
it  is  well  to  avoid  it  as  a  remedy  here  entirely,  and  depend  upon 
arseniate  of  quinia,  3x  trituration,  as  this  is  acceptable,  easily  toler- 
ated, and  very  effective,  though  not  as  rapid  in  its  influence  as  qui- 
nine, in  appropriate  cases.  The  sedative  being  administered  in  the 
doses  already  suggested,  three  grains  of  arseniate  of  quinia  may  be 
administered  every  four  hours,  until  the  disease  is  arrested.  Some- 
times a  typhoid  condition  seems  to  approach;  the  patient  becomes 
somnolent,  semi-delirious,  and  prostrated,  and  echinacea  may  prove 
the  best  sedative.  The  combination  of  cdstonia  with  the  arseniate  of 
quinia  is  often  a  good  measure,  the  combination  being  that  of  two 
or  three  grains  of  alstonia  with  the  same  quantity  of  arseniate  of 
quinia  3x,  in  capsule. 

During  the  height  of  the  exacerbation,  sponging  of  the  surface, 
at  occasional  intervals,  will  be  advisable,  and  cold  cloths  on  the 
forehead,  or  sponging  the  head  and  fanning,  will  assist  in  relieving 
the  unpleasant  head-symptoms.  The  diet  should  be  light,  liquid 
food  being  preferable,  and  it  is  needless  to  urge  much  upon  the 
patient,  as  the  probability  of  an  early  termination  of  the  disease  will 
render  it  important  that  the  stomach  should  not  be  burdened  with 
food  during  the  height  of  the  disease.  Rice-water,  milk,  toast,  and 
other  light  articles,  may  be  taken  during  the  remissions. 


MALARIAL  FEVER:   PERNICIOUS  FORMS.  235 

PERNICIOUS  MALABIAL  FEVER. 

Synonyms. — Congestive  Fever;  Tropical  Typhoid  Fever;  Per- 
nicious Fever. 

Definition. — A  malarial  disease,  characterized  by  severe  ana- 
tomical lesions,  and  attended  by  rapid  prostration  and  death,  unless 
promptly  treated  during  its  early  stages.  A  malignant  form  of  mala- 
rial disease. 

Etiology. — The  cause  of  this  disease  is  identical  with  that  of 
other  forms  of  malarial  fever,  the  malignant  character  being  due  to 
a  predisposing  condition  of  the  system,  to  an  average  high  tempera- 
ture, or  to  epidemic  influences.  It  prevails  quite  extensively  where 
the  average  temperature  reaches  for  a  time  65°,  but  it  may  occasion- 
ally be  observed  in  more  temperate  regions,  though  not  with  such 
marked  fatality.  I  have  seen  several  well  marked  cases  of  the  com- 
atose variety  of  this  disease  in  Ohio,  and  one  case  of  the  delirious 
form  in  Missouri,  though  all  were  promptly  amenable  to  treatment 
but  one,  a  comatose  case,  in  which  treatment  was  rejected  early. 

Pathology. — The  morbid  lesions  of  pernicious  malarial  fever 
are  less  marked  in  autopsies  than  those  of  malarial  cachexia.  In 
the  blood  the  abundant  destruction  of  red  corpuscles  is  notable,  as 
well  as  the  large  amount  of  black  pigment  derived  from  them,  found 
particularly  in  the  visceral  capillaries.  A  crenated  condition  of  the 
red  corpuscles  may  be  found  upon  microscopical  examination,  and 
the  relative  number  of  white  corpuscles  is  large,  this  being  due,  not 
to  any  marked  increase  in  number,  but  to  the  rapid  destruction  of 
the  red  corpuscles  which  has  occurred.  The  spZeen-changes,  common 
to  acute  malarial  affections,  are  also  present.  The  organ  is  swollen, 
soft,  and  almost  black  in  color,  the  fluid  contained  being  dark  and 
watery.  The  kidneys  are  hypersemic  and  pigmented,  and  the  heart 
is  pale  and  flabby.  The  lungs  are  congested,  the  lower  lobes  being 
especially  engorged.  The  nervous  system  is  more  or  less  involved, 
the  brain  being  hyperaenic,  the  ventricles  filled  with  serum,  and  the 
cerebral  capillaries  blocked  with  debris  of  broken-down  corpuscles, 
hematozoa,  and  pigment 

Symptoms. — Pernicious  fever  may  assume  a  variety  of  types, 
and  it  may  appear  in  the  beginning  as  an  intermittent  or  remittent 
form  of  fever.  It  may  begin  as  an  ordinary  intermittent  and  assume 
the  character  of  pernicious  fever  after  one  or  two  paroxysms;  or  it 
may  begin  as  an  ordinary  remittent  and  continue  so  for  several  days 
before  the  pernicious  symptoms  are  manifested.  In  other  cases,  a 
premonitory  chill  initiates  the  symptoms,  which  immediately  appear 
as  those  of  one  of  the  varieties  of  pernicious  fever. 


23G 


SPECIFIC  INFECTIOUS  DISEASES. 


Several  varieties  of  this  fever  have  been  described,  the  disease 
seeming  to  manifest  itself  in  a  different  manner  in  different  localities, 
or  in  different  seasons.  It  has  been  asserted  that  epidemic  influ- 
ences operate  at  different  times  to  determine  the  prevalence  of  par- 
ticular varieties.  'Though  the  pathological  lesions  are  but  slightly 
varied  in  different  cases,  the  symptoms  are  of  a  marked  diversity  of 
character.  Seven  prominent  varieties  may  be  mentioned,  viz.,  the 
comatose,  the  delirious,  the  gastro-enteric,  the  icteric,  the  algid, 
the  hemorrhagic,  and  the  colliquative. 

The  symptoms  of  the  comatose  variety  are  marked  almost  from 
the  beginning.  An  ordinary  attack  of  intermittent  or  remittent 
fever  may  ensue,  but  the  hot  stage  is  attended  by  a  comatose  condi- 
tion, from  which  it  is  almost  impossible  to  arouse  the  patient.  He 
lies  in  a  state  of  stupor  and  unconsciousness,  upon  his  back,  his  face 
upturned,  flushed,  eyes  congested,  pupils  dilated,  pulse  slow  and 
labored,  respiration  slow,  deep  and  stertorous.  The  temperature  now 

ranges  from  105°  to  107°  F.,  in  the 
axilla.  There  is  loss  of  power  of 
the  sphincters,  involuntary  evacua- 
tion from  the  bladder  occurring,  or, 
instead,  the  urine  may  be  retained, 
and  the  bowels  move  involuntarily. 
The  patient  passes  deeper  and 
deeper  under  this  influence,  the  com- 
atose state  becoming  more  marked 
for  ten  or  twelve  hours,  when  a 
moisture  may  appear  upon  the  fore- 
head, a  perspiration  break  out  over 
the  entire  surface,  and  the  patient 
awake,  perspiring  profusely.  An 
intermission  or  remission  now  fol- 
lows, when  a  more  severe  attack 
is  attended  by  all  the  symptoms  of 
the  former  comatose  condition,  in  an 
aggravated  form,  aud  the  patient 

PEBNICIOU*  MALABIAL  FKVEB:  maV    t>aSS   into    a    fatal    stupor.       Or, 

COMATOSE  VARIETY.  J     r  ... 

he  may  pass  into  a  condition  of  apparent  death,  remain  in  that  state 
for  hours.  But  almost  invariably  fatal  results  follow,  the  prognosis 
becoming  more  unfavorable  with  each  succeeding  exacerbation. 

In  the  delirious  form,  after  the  patient  passes  into  the  hot  stage, 
active  delirium  sets  in,  the  patient  raving  and  tossing,  and  finally,  as 
the  delirious  stage  advances,  attempting  to  get  out  of  bed,  and  resist- 
ing opposition  by  struggling  furiously.  This  may  last  for  hours,  the 


MALARIAL  FEVER:   PERNICIOUS  FORMS. 


237 


patient  screaming  wildly  and  endeavoring  to  escape  from  the  room. 
The  face  is  flushed,  the  eyes  congested,  the  pulse  full  and  bounding. 
The  temperature  may  be  very  high,  often  reaching  107°  or  108°  F., 
in  the  axilla.  This  may  go  on  for  hours,  the  hot  stage  finally  termi- 
nating in  a  short  remission,  or  the  patient  sinking  into  a  condition 
of  fatal  coma.  If  a  remission  occurs,  another  stage  of  delirium  soon 
follows,  and  a  fatal  termination  is  almost  certain  to  result. 

In  the  gastro-enteric  variety,  the  prominent  feature  of  the  hot 
stage  is  violent  vomiting  and  purging.  The  efforts  are  attended  by 
great  prostration,  by  cramps  in  the  extremities,  weight  and  burning 
in  the  stomach,  and  intense  thirst.  The  symptoms  are  similar  to 
those  of  Asiatic  cholera,  except  that  the  evacuations  are  not  the 
rice-water  discharges  of  that  disease,  they  usually  being  blood-stained 
in  appearance,  or  like  the  washings  of  raw  meat.  Sometimes,  how- 
ever, the  evacuations  resemble  those  of  cholera.  Authors  describe 
a  peculiar  respiration  attending  this  disease,  it  being  a  double  sigh- 
ing inspiration,  followed  by  a  double  sighing  expiration.  Collapse 
and  death  are  likely  to  follow  the  first  attack. 

The  algid   variety  is  what   is  commonly   known  as  "congestive 

chill."  The  surface  of  the  body 
becomes  of  marble  coldness  after 
the  initiatory  chill  is  past  and 
the  hot  stage  of  an  intermittent 
or  the  exacerbation  of  a  remit- 
tent has  begun.  The  surface  of 
the  body  begins  to  grow  cold,  and 
finally  only  the  surface  of  the 
abdomen  is  warm  to  the  touch, 
while  the  patient  complains  of 
gastric  heat  and  thirst.  The  rec- 
tal temperature  may  run  as  high 
as  104°  or  105°  F.,  or  in  some 
cases,  even  higher.  The  skin 
becomes  clammy,  the  pulse  slow 
and  faltering,  the  axillary  tem- 
perature falls  as  low  as  88°  or 
lower,  the  extremities  are  like 
marble  in  coldness,  the  tongue  is 
cold,  white,  and  clammy,  the 
breath  is  chilly,  and  the  voice 
becomes  feeble  and  indistinct. 
Sometimes  there  is  coma  in  this  form,  and  sometimes  delirium. 
Usually  the  patient  is  conscious,  however,  and  does  not  realize  much 


PEBJTICIOUS  MALARIAL  FEVEB: 
ALGID  VARIETY. 


238  SPECIFIC  INFECTIOUS  DISEASES. 

discomfort,  except  that  of  exhaustion  and  great  internal  heat.  The 
common  termination  of  this  condition  is  death,  the  disease  going 
rapidly  forward  to  a  fatal  termination. 

The  remarkable  symptom  in  the  icteric  variety  is  the  yellow  tinge 
of  the  skin,  marking  a  profoundly  jaundiced  condition.  The  disease 
begins  with  a  severe  chill,  which  is  protracted,  and  during  which  a 
remarkable  yellowness  of  the  skin  develops.  This  jaundice  involves  the 
conjunctiva  and  entire  skin,  and  gradually  deepens,  until  the  surface 
is  markedly  greenish-yellow.  Vomiting  usually  sets  in  at  an  early 
period,  and  this  is  attended  by  a  bilious  diarrhoea.  Severe  headache, 
pain  and  fullness  in  the  spleen  and  over  the  kidneys,  numbness  in 
the  limbs,  and  great  restlessness,  attend.  The  urine  is  scanty  and 
dark-colored,  so  much  so  as  to  constitute  the  condition  termed  "mel- 
anuria."  The  pulse  is  small  and  frequent,  and  respiration  labored. 
As  the  hot  stage  arrives,  the  pulse  becomes  full,  rapid,  and  bounding, 
the  skin  very  dry  and  hot,  the  temperature  high  (106°  or  107°),  the 
headache  bursting,  and  the  thirst  intense.  Within  three  or  four 
hours,  this  stage  is  liable  to  terminate  fatally.  If  the  skin  becomes 
moist,  a  sweating  stage  comes  on,  and  a  remission  becomes  estab- 
lished. But  each  succeeding  paroxysm  becomes  more  and  more 
severe,  unless  the  disease  is  arrested  by  treatment,  until  a  fatal  ter- 
mination ensues.  This  form  occurs  eudemically  in  certain  local- 
ities, prevailing  whenever  any  form  of  pernicious  fever  appears  there. 

The  hemorrhagic  variety  is  characterized  by  hemorrhage  from  the 
kidneys.  The  fever  may  be  intermittent,  remittent,  or  continuous  in 
character.  The  subjects  are  usually  victims  of  profound  mercurial- 
ism,  of  chronic  malarial  cachexia,  or  chronic  alcoholism.  It  occurs 
in  tropical  regions,  and  is  attended  by  symptoms  of  jaundice,  it  being 
a  combination  of  the  icteric  and  hemorrhagio  states.  It  is  com- 
mon in  the  swampy  regions  of  the  Southern  States,  Alabama, 
Mississippi,  Arkansas,  and  Louisiana  being  the  theater  of  its  action, 
where  low  marshy  regions  along  the  rivers  furnish  the  requisite  con- 
ditions for  its  development  Hemorrhage  from  the  kidneys  may 
occur  in  almost  any  region  and  attend  malarial  disease,  but  in  many 
cases  it  is  not  of  the  malignant  character  that  is  comprehended  by 
the  hematuria  of  pernicious  hemorrhagic  fever.  This  disease  resem- 
bles yellow  fever  in  many  of  its  characteristics,  but  it  does  not  occur 
epidemically,  and  there  is  more  splenic  enlargement. 

Blooa  appears  in  the  urine  sometimes  during  the  cold  stage,  but 
more  profuse  hemorrhage  is  apt  to  occur  during  the  period  of  febrile 
action.  The  urine  is  dark,  acid,  and  albuminous,  and  contains  tube- 
casts  and  blood-corpuscles,  there  being  a  copious  sediment  deposited 
upon  standing.  Where  a  marked  remission  occuis,  the  hemorrhage 


MALARIAL  FEVER  :   PERNICIOUS  FORMS.  239 

may  cease  for  the  time  being,  but  it  returns  upon  the  onset  of  the 
following  paroxysm  or  exacerbation.  Icterus,  vomiting,  severe  head- 
ache, aud  pain  in  the  back  and  loins,  attend.  The  respiration  is 
sighing  and  oppressed,  the  decubitus  is  dorsal,  the  tongue  is  first 
broad  and  moist,  and  covered  with  a  pasty  white  coating,  but  later, 
after  icteric  symptoms  have  developed,  the  coating  becomes  yellow. 
In  fatal  cases,  it  turns  dry  and  brown,  or  becomes  covered  with  black 
sordes.  The  pulse  is  full  and  oppressed.  The  bowels  are  often 
constipated  in  the  beginning,  but  a  watery  diarrhoea  appears  later, 
the  dejections  beinsj  yellow,  green,  or  black.  The  temperature 
runs  from  106°  to  108°  during  the  hot  stage,  and  this  continues  for 
several  days,  the  decline  being  attended  by  a  period  of  profound 
adynamia,  which  lasts  for  several  days.  This  disease  is  very  apt  to 
terminate  fatally. 

In  the  colliquative  variety,  a  prostrating  sweat  follows  the  hot 
stage,  and  continues  during  the  intermission.  The  pulse  is  feeble 
and  oppressed,  the  respiration  is  sighing  and  labored,  and  the  suc- 
ceeding exacerbation  begins  with  the  patient  very  much  prostrated 
and  exhausted.  After  two  or  three  such  periods,  he  sinks  and  dies 
of  exhaustion.  In  other  cases,  severe  hemateinesis  or  hematuria 
may  occur  during  the  sweating  stage,  and  rapid  prostration  follow, 
often  with  fatal  results. 

Diagnosis. — There  is  little  probability  of  confounding  this  dis- 
ease with  anything  but  yellow  fever,  and  this  might  be  the  case  in 
the  icteric  form,  if  it  were  not  recollected  that  yellow  fever  occurs 
epidemically,  and  that  it  is  contagious,  which  is  not  the  case  with 
icteric  pernicious  fever.  The  gradual  rise  in  temperature  and  insid- 
ious invasion  of  the  acme  stage,  with  the  abdominal  symptoms, 
would  usually  distinguish  typhoid  fever.  When  gastro-intestinal 
symptoms  are  present  in  pernicious  fever,  they  are  violent  in  char- 
acter, resembling  those  of  cholera  or  yellow  fever.  The  absence  of 
an  epidemic  will  exclude  danger  of  confounding  it  with  either  of 
these  diseases. 

Treatment. — The  violence  of  the  attack  in  pernicious  fever  will 
usually  interfere  with  the  selection  of  remedies  on  the  lines  usu,.Uy 
suggested  in  specific  medication.  However,  prominent  indications 
in  this  direction  should  not  be  disregarded,  as  some  prominently 
indicated  remedy,  such  as  sodium  sulphite,  might  be  the  turning  pivot 
upon  which  the  life  of  a  patient  would  depend.  The  simple  admin- 
istration of  quinine,  as  advised  by  some  authors,  is  certainly  not  all 
that  can  be  advised,  though  it  is  admittedly  an  important  item  of  the 
treatment; 

The  comatose  variety  should  be  treated  by  a  hot  bath,  which  may 


240  SPECIFIC  INFECTIOUS  DISEASES. 

be  administered  by  packing  the  patient  with  flannels  wrung  out  of 
hot  water,  while  fall  doses  of  jaborandi  are  swallowed  until  per- 
spiration has  been  established.  If  the  patient  cannot  be  aroused 
sufficiently  to  be  induced  to  swallow  the  drug,  one-fourth  grain  of 
pilocarpin  may  be  administered  hypodermically,  and  repeated  in  an 
hour,  if  a  decided  action  is  not  manifested  by  that  time.  As  soon  as 
the  action  of  the  drug  is  manifest  by  the  indication  of  perspiration, 
twenty  or  thirty  grains  of  quinine,  either  the  bisnlphate  or  sulphate, 
shon .d  be  administered  hypodermically,  and  the  injection  should  be 
repeated  every  two  hours  until  the  patient  has  passed  under  the 
influence  of  the  drug,  and  is  out  of  immediate  danger.  As  soon  as 
the  attack  is  arrested,  means  should  be  taken  to  remove  such  spe- 
cific conditions  as  are  prominently  manifested  by  the  individuality 
of  the  case.  Portal  congestion,  a  condition  almost  certain  to  be 
present,  should  be  met  with  pdymnia  or  carduus  marianvs;  gastric 
conditions  should  be  corrected,  and,  as  there  will  be  likely  to  be 
acidity  with  sepsis,  sulphite  of  sodium  will  meet  the  indication,  '-tongue 
loaded  with  pasty-white  coating."  Other  specific  indications  should 
be  met,  as  far  as  possible.  Gastric  irritation  may  be  treated  with 
aconite  and  rhus  tax.  If  practicable,  the  patient  should  be  removed 
from  the  intensely  malarious  district  into  the  most  salubrious  neigh- 
borhood possible,  until  time  has  been  allowed  for  recuperation. 

In  the  treatment  of  the  delirious  variety  the  hot  pack  is  especially 
applicable,  and  here  also  the  hypodermic  use  of  pilocarpin  will  be  the 
most  prompt  and  effectual  method  of  bringing  the  circulation  under 
the  influence  of  a  sedative  and  equalizer,  and  preparing  the  way  for 
the  appropriation  of  quinine.  Whatever  form  or  variety  of  pernicious 
fever  we  may  encounter,  there  is  an  overpowering  accumulation  of 
the  provoking  element  in  the  circulation,  which  oppresses  the  vaso- 
motor  centers,  and  causes  congestion  of  internal  organs.  To  equal- 
ize the  circulation  then  is  the  first  requirement,  and  nothing  will  do 
this  so  readily  and  promptly,  considering  the  facility  of  administra- 
tion, as  pilocarpin.  A  flannel  blanket  wrung  out  of  hot  water  and 
wrapped  around  the  patient  as  hot  as  can  be  borne  without  scald- 
ing, answers  the  double  purpose  of  confining  a  struggling  patient, 
and  of  equalizing  the  circulation  and  lowering  the  temperature. 
Under  the  influence  of  these  measures,  t  he  patient  will  soon  become 
calm,  and  fall  into  a  sleep,  from  which  he  will  awake  apparently 
almost  recovered.  However,  the  antiperiodic  must  be  promptly 
administered,  as  a  second  paroxysm  is  liable  to  appear,  in  worse 
form  than  the  first 

In  the  icteric  form,  the  addition  of  p&ymnia  uvedalia  is  an  impor- 
tant aid  to  treatment,  and  here  the  dose  must  be  large,  fifteen  or 


MALAEIAL  FEVER:   PERNICIOUS  FORMS.  241 

twenty  drops  of  the  specific  medicine  every  hour  or  half  hour  not 
being  too  much.  There  is  no  objection  to  combining  chionantJius 
with  it,  though  the  action  of  this  drug  is  too  slow  for  the  speedy 
effect  here  desired. 

There  is  no  objection  to  the  employment  of  the  same  treatment 
in  the  colliquative  form  of  this  disease,  for,  though  there  may  be  pro- 
fuse sweating,  there  is  want  of  proper  circulation — an  oppression  of 
the  nervous  centers  which  regulate  the  circulatory  system — and  pil- 
ocarpin  will  afford  good  results  here,  establishing  more  of  a  salutary 
condition  in  the  sudoriparous  glands,  and  preparing  the  way  for  the 
kindly  action  of  the  antiperiodic. 

It  must  be  recollected  that  many  cases  of  this  kind  are  attended 
by  persistent  vomiting,  of  a  character  which  is  very  difficult  to 
speedily  control;  therefore,  hypodermic  medication  offers  the  most 
rational  means  for  the  administration  of  remedies,  as  we  are  assured 
that  it  will  be  retained  until  its  effects  have  been  produced.  Any 
one  of  the  special  sedatives  may  be  employed  hypodermically,  aco- 
nite, belladonna,  veratrum,  or  gelsemium  acting  as  effectively  that 
way  as  per  mouth,  though  aconite  and  belladonna,  if  not  veratrum, 
better  be  omitted,  since  the  large  dose  of  such  powerful  remedies  is 
never  advisable,  and  the  large  dose  must  be  administered  here  in 
order  to  get  speedy  results. 

It  will  be  observed  that  little  discrimination  is  made  as  to  the 
treatment  of  different  varieties,  and  such  is  not  necessary.  For, 
though  the  symptoms  may  vary  widely,  there  is  such  a  sameness  in 
etiological  and  pathological  respects  that  it  would  be  folly  to  waste 
valuable  and  often  vital  moments  treating  accidental  symptoms. 
These  may  all  be  hunted  up  and  prescribed  for  after  the  patient's 
life  has  been  saved  from  immediate  jeopardy,  and  we  have  a  case 
of  malarial  cachexia  to  treat. 

HYPODERMIC  INJECTION  OF  QUININE  IN  MALARIAL  FEVER. — On  this 
subject  I  will  quote  an  article  by  H.  Martyn  Scudder,  M.  D.,  pub- 
lished in  the  Medical  Record  in  1885 : 

"About  a  year  after  my  arrival  in  India  I  was  placed  in  charge 
of  a  general  hospital  and  dispensary,  situated  about  seven  miles 
from  Madras,  in  a  town  which,  with  its  suburbs,  contained  a  popu- 
lation of  over  thirty  thousand  inhabitants.  In  the  year  1876  I  was 
induced,  by  several  articles  published  in  the  British  and  Indian 
medical  journals,  to  try  extensively  the  treatment  of  intermittent 
and  remittent  fevers  by  the  hypodermic  injection  of  sulphate  of  qui- 
nine. As  over  nine  thousand  patients  were  annually  treated  in  this 
hospital  and  dispensary,  I  was  enabled  to  try  this  treatment  on  a 
large  settle. 

IT 


242  SPECIFIC  INFECTIOUS  DISEASES. 

"At  first  I  employed  a  solution  made  with  ordinary  sulphate  of 
quinine  and  dilute  hydrochloric  acid,  and  I  was  astonished  at  the 
wonderful  result  produced  by  these  hypodermic  injections.  Cases 
that  had  been  taking  twenty  arid  thirty  grains  per  diem  by  the  mouth 
without  any  apparent  effect,  were  cured  at  once  by  the  injection  of 
from  eight  to  twelve  grains.  In  the  first  100  cases,  subjected  to 
this  treatment,  I  had  5  cases  of  abscess  following  the  injections. 
Not  being  satisfied  with  this  result,  I  determined  to  try  a  solution 
of  the  quinisB  sulph.  solubil.  (an  English  preparation  very  similar  to 
our  bisulphate),  prepared  with  a  little  tartaric  acid.  I  found  this  a 
great  success — I  might  almost  say  a  perfect  success.  I  have  used 
this  injection  in  over  two  thousand  cases  without  any  bad  effects, 
with  the  exception  of  one  case  of  small  abscess.  Even  in  this  case 
I  am  inclined  to  think  there  would  have  been  no  abscess  if  the 
patient's  arm  had  been  firmly  held,  and  if  the  operator  had  not  been 
interrupted  by  the  violent  movements  of  the  chilL 

"During  the  last  three  years  of  my  residence  in  India  I  was  set- 
tled on  the  Neilgherry  Hills,  where  I  had  a  good  opportunity  of  car- 
rying on  this  mode  of  treatment  by  hypodermic  injection,  and  of 
ascertaining  that  it  was  as  efficacious  with  Englishmen  as  it  had 
proved  to  be  with  the  natives.  Near  the  tops  of  these  Neilgherry 
Hills,  at  an  elevation  of  about  six  thousand  and  eleven  thousand 
feet  above  the  level  of  the  sea,  are  situated  the  two  large  sanitaria 
of  South  India,  with  an  English  population  of  from  five  thousand  to 
ten  thousand,  according  to  the  season  of  the  year.  The  climate  of 
these  hills  at  this  elevation  being  cool  and  healthy,  Europeans  are 
able  to  live  there  in  comfort  and  bring  up  their  families.  A  great 
number  of  English  gentlemen  are  residents  upon  these  hills,  being 
engaged  in  the  cultivation  of  coffee,  tea,  cinchona,  or  'planting,' 
as  it  is  termed.  To  work  their  large  and  valuable  estates  great 
numbers  of  native  laborers  are  employed.  These  plantations  are 
situated  on  the  slopes  of  the  hills,  at  an  average  elevation  of  three 
thousand  five  hundred  feet,  and  therefore  below  what  is  called  "fever 
range"  that  is,  the  hilly  or  mountain  tracts  of  South  India  are  gen- 
erally infested  with  malaria  until  you  reach  an  elevation  of  over 
five  thousand  feet.  At  certain  times  of  the  year  it  is  unsafe  to  sleep 
even  for  a  single  night  on  these  estates.  The  native  laborers  are 
obliged,  however,  to  live  down  there,  and  are  therefore  constantly 
prostrated  with  fever.  I  have  frequently  been  called  to  visit  one  of 
these  estates,  and  in  a  single  morning  would  often  have  to  adminis- 
ter hypodermic  injections  of  quinine  to  over  fifty  of  these  native 
laborers.  In  addition  to  constantly  and  regularly  employing  hypo- 
dermic injections  of  quinine  in  the  treatment  of  malarial  fevers,  I 


MALARIAL  FEVER:    TYPHO-MALARIAIj  FORM.  243 

administered  quinine  in  this  way  in  puerperal  septicaemia,  where  I 
found  it  had  a  very  beneficial  effect. 

"A  considerable  number  of  cases  of  puerperal  septicaemia  oc- 
curred in  the  lying-in  ward  of  the  General  Hospital  and  Dispensary 
already  alluded  to.  The  native  doctors  and  midwives  have  no  real 
knowledge  of  anatomy  and  physiology,  and  they  often  employ  most 
violent  means  to  hasten  difficult  labors.  It  is  therefore  not  at  all 
surprising  that  many  cases  of  septicaemia  and  peritonitis  result 

"I  have  already  mentioned  that  the  solution  generally  used  was 
composed  of  quiniae  sulph.  solubil.,  tartaric  acid,  and  distilled  water, 
the  strength  of  the  solution  varying  from  fourteen  per  cent,  to  twenty 
per  cent.  With  adults  I  usually  injected  two  syringefuls  (that  is, 
from  five  to  eight  decigrammes)  into  the  upper  and  outer  part  of 
the  arm,  or  in  the  back  of  the  shoulder,  pushing  the  needle  well 
down  into  the  subcutaneous  tissues  and  even  into  the  muscle.  The 
pain  produced  was  always  trifling  and  of  short  duration.  Some- 
times a  little  redness  and  very  slight  swelling  occurred,  but  soon 
disappeared.  I  once  administered  to  an  English  army  officer,  taken 
suddenly  with  a  congestive  chill,  eight  syringefuls  of  a  sixteen  per 
cent  solution  in  twelve  hours,  with  the  very  best  of  results,  except 
that  he  was  somewhat  deaf  for  a  day  or  two.  Of  course  I  do  not 
mean  to  assert  that  this  treatment  by  hypodermic  injection  always 
drove  the  malarial  poison  entirely  out  of  the  system,  or  effected  a 
permanent  cure ;  but  one  or  two  injections  nearly  broke  up  the  fever, 
and  effected  a  cure  at  the  time,  so  that  a  patient  would  have  no 
return  of  the  fever,  unless  he  exposed  himself  anew  by  visiting  a 
locality  where  malarial  fever  was  rife,  or  allowed  his  general  health 
to  run  down.  I  had  two  patients — wealthy  English  gentlemen — who 
were  accustomed  to  come  every  few  months  and  get  me  to  give  them 
a  hypodermic  injection  of  quinine  as  a  prophylactic  measure  when 
they  were  about  to  visit  a  notoriously  feverish  locality.  During  the 
eighteen  months  that  I  have  been  practicing  here  in  Chicago,  I  have 
made  the  use  of  hypodermic  injections  of  quinine  several  times,  with 
perfect  success.  In  conclusion,  to  show  what  perfect  confidence  I 
have  in  this  mode  of  treatment,  I  have  only  to  mention  that  I  have 
had  quinine  injected  into  my  own  arm  on  two  occasions." 

TYPHO-MALAEIAL  FEVEB. 

Synonyms. — Continued  Malarial  Fever;  Bemitto-Typhus  Fever. 

Definition. — A  term  applied  to  forms  of  malarial  fever  present- 
ing features  of  a  continued  type,  such  as  nervous  prostration, 
absence  of  appreciable  relief  during  remissions,  tongue  indications 


244  SPECIFIC  INFECTIOUS  DISEASES. 

foreign  to  those  of  pure  malarial  iever,  and  pronounced  aggravation 
from  the  influence  of  quinine. 

Nature. — The  term  " typho-nialarial  fever"  has  been  something 
of  an  omnibus,  under  which  quite  a  variety  of  conditions  have  been 
grouped,  the  only  specific  characteristic  common  to  all  being  the 
manifestation  of  malaria  as  exhibited  by  marked  periodicity  in  th<> 
beginning.  Some  authors  discard  the  term  altogether,  on  the  ground 
that  true  typho-malarial  fever  is  a  complication  of  typhoid  fever  with 
malaria,  and  that  there  is  no  excuse  for  classifying  a  new  disease. 
If  this  were  true,  it  might  be  wise  to  adopt  such  a  course;  but  every- 
body who  has  had  much  experience  in  malarious  regions  knows  that 
oases  of  fever  frequently  occur  here  which  are  different  from  pure 
malarial  fever,  in  their  tendency  to  run  a  continued  course  (BO  far 
as  the  unpleasantness  of  their  symptoms  is  concerned),  with  typhoid 
symptoms,  in  spite  of  antiperiodics  and  other  treatment  which  will 
arrest  ordinary  malarial  attacks,  and  which  are  not  true  enteric  fever, 
as  there  is  nothing  in  their  history  to  indicate  a  possibility  of  such . 
infection,  and  abdominal  symptoms  are  the  exception  rather  than 
the  rule ;  and  then  this  is  an  accidental  complication,  instead  of  an 
important  feature  of  the  disease. 

Other  diseases  than  typhoid  fever  may  be  complicated  with  mala- 
ria, such,  for  instance,  as  dysentery  and  pneumonia,  and  when  these 
diseases  occur  as  an  epidemic  where  malarious  conditions  are  pre- 
vailing, we  may  have  typho-malarial  dysentery  or  typho-malarial 
pneumonia;  but  this  kind  of  a  complication  is  not  the  condition  for 
which  the  name  is  here  intended. 

The  name  had  its  origin  about  the  time  of  the  last  American  war, 
when  the  soldiers  of  the  north  were  stricken  on  the  banks  of  the 
Chickahominy  with  a  severe  and  fatal  disease,  the  symptoms  doubt- 
less being  due  partly  to  the  paludal  influence  of  the  surrounding 
swamps,  and  partly  to  such  anti-hygienic  influences  as  the  deposi- 
tion of  much  fecal  material  upon  the  surface,  to  contaminate  neigh- 
boring springs  and  other  sources  of  supply  of  drinking  water,  with 
the  typhoid  fever  bacillus.  Doubtless  this  was  a  combination  of 
malaria  and  true  typhoid  fever,  a  condition  which  it  is  not  the  inten- 
tion to  discuss  here.  I  have  appropriated  the  name  for  an  entirely 
different  disease. 

The  object  of  this  article  is  to  discuss  a  malarial  fever  in  which 
there  are  typhoid  symptoms,  without  combination  of  specific  typhoid 
fever  conditions — a  condition  often,  but  not  always,  characterized  by 
marked  periodicity,  occurring  in  malarious  districts,  but  in  which 
the  measures  which  arrest  ordinary  malarial  fevers  prove  futile,  and 
in  which  the  patient  passes  through  various  stages  of  septic  fever, 


MALARIAL  FEVER:   TYPHO-MALAKIAL  FORM.  246 

as  indicated  by  the  tongue-changes  and  accompanying  symptoms, 
the  disease  running,  in  spite  of  treatment,  from  fourteen  to  twenty- 
one  days. 

The  following  notes  on  the  parasite  of  malaria,  by  TJ.  S.  N.  Sur- 
geon Craig,  suggest  the  reason  for  the  disappearance  or  occasional 
absence  of  marked  periodicity,  as  well  as  throwing  light  upon  the 
etiology  of  malarial  diseases  in  general : 

"It  is  during  the  apyrexial  period  that  the  organisms  grow,  pro- 
ducing few  or  no  symptoms.  It  is  only  when  the  stage  of  segmenta- 
tion is  approached  that  the  temperature  begins  to  rise,  and  reaches 
the  acme  about  the  time  that  segmentation  has  been  completed; 
then  declining  to  normal,  the  paroxysm  lasting  an  indefinite  period, 
depending  on  the  potency  and  quantity  of  the  toxine  evolved. 

"In  the  ordinary  tertian,  and  double  tertians,  the  quartans  and 
their  combinations,  the  length  of  the  paroxysm  averages  from  about 
six  to  ten  hours. 

"In  the  sestivo-autumnal,  or  the  remittents,  as  they  are  com- 
monly called,  the  duration  of  the  paroxysm  is  much  longer,  averag- 
ing from  eighteen  to  twenty-two  hours,  or  even  as  long  as  thirty-six 
hours  in  some  cases;  thus,  it  is  the  overlapping  of  these  paroxysms 
which  gives  the  irregularly  continuous  fever;  that  is,  the  toxin  pro- 
duced by  one  set  of  organisms  does  not  become  eliminated  before 
the  adveut  of  a  fresh  quantity  of  toxin  by  the  succeeding  set  of 
organisms. 

"In  the  pernicious  and  congestive  forms  of  these  fevers,  the  toxin 
is  in  such  a  virulent  form  that  sometimes  one  paroxysm  is  sufficient 
to  cause  the  death  of  the  patient. 

"It  is  not  the  high  temperature  which  kills  in  all  cases,  for  we  find 
that  in  some  c  ises  the  temperature  becomes  subnormal,  96°  F.  or 
less,  and  remains  so,  the  patient  dying  in  a  condition  of  coma,  just 
as  in  the  hyperpyrexial  case." 

Etiology. — As  will  be  inferred  from  the  foregoing,  the  etiology 
is  somewhat  obscure.  Undoubtedly  the  plasmodium  raalariae  figures 
as  one  of  the  exciting  causes,  but  there  must  be  an  additional  factor, 
or  else  it  would  not  be  so  markedly  different  from  pure  malarial 
fever  in  its  clinical  characteristics. 

This  is  evidently  not  the  specific  bacillus  of  true  typhoid  fever,  for 
the  disease  cannot  be  traced  to  fecal  material,  nor  does  it  propagate 
its  kind  in  the  manner  peculiar  to  that  disease.  Indeed,  it  is  doubt- 
ful that  it  is  contagious,  or  even  infectious,  except  so  far  as  the  mala- 
rial element  is  concerned. 

It  is  probable  that  the  condition  depends  upon  a  peculiar  state 
of  the  system,  brought  about  by  various  anti-hygienic  causes,  such 


246  SPECIFIC  INFECTIOUS  DISEASES. 

as  depressing  influences  from  mental  worry,  overwork  with  anxiety, 
retained  secretions,  improper  diet,  or  vitiated  air,  in  combination 
with  the  ordinary  causes  of  malaria. 

Loomis  asserts  that  sewer  gases  seem  to  be  the  elements  which 
have  predisposed  to  it,  in  cases  which  have  come  under  his  notice. 

Symptoms. — It  is  difficult  to  describe  the  symptoms  of  this 
disease,  as  different  cases  vary  so  much.  Some  peculiarities  may  be 
mentioned,  however,  which  are  applicable  to  many  of  them.  They 
run  from  fourteen  to  twenty-one  days,  in  spite  of  treatment  While 
an  ordinary  case  of  malarial  fever,  whether  intermittent  or  remittent, 
can  be  arrested  within  the  first  week,  such  treatment  usually  fails 
to  arrest  this  variety,  and  it  persists  in  running  through  its  course. 
Most  cases  also  present  marked  malarial  symptoms  in  the  beginning, 
in  the  manifestation  of  chills  and  other  periodicity,  and  later  grow 
out  of  this  into  a  more  continued  type,  as  the  nervous  system 
becomes  more  and  more  involved. 

While  some  observers  state  that  intestinal  complication  is  a  com- 
mon condition,  my  experience  has  been  that  there  is  little  disturb- 
ance of  the  bowels,  though  in  a  large  class  of  cases  gastric  irrita- 
tion is  common.  In  those  cases  manifesting  intestinal  irritation,  the 
season  of  the  year  and  the  character  of  food  eaten  prior  to  the  attack 
are  liable  to  play  provoking  parts. 

Two  prominent  classes  of  cases  are  found,  and  I  shall  divide  all 
cases  into  these  two  classes,  though  occasionally  a  case  will  be 
encountered  which  cannot  be  included  in  either  one.  We  will  call 
them  the  septic  class  and  the  nervous  class. 

In  the  septic  class  the  attack  is  usually  abrupt  and  severe.  There 
is  a  marked  and  prolonged  chill,  and  this  may  be  repeated  every 
day  for  three  or  four  days,  resembling  the  paroxysms  of  an  inter- 
mittent fever;  or,  instead,  there  may  be  but  the  one  chill,  and  the 
remissions  and  exacerbations  of  a  remittent  fever  may  mark  the 
onset  Instead  of  the  marked  relief  that  attends  the  intermissions 
or  remissions  of  an  ordinary  malarial  fever,  however,  the  patient 
suffers  continually,  and  is  not  inclined  to  get  out  of  bed,  marked 
prostration  manifesting  itself  from  the  start.  During  the  exacerba- 
tions, the  temperature  ranges  from  103°  to  105°  F.,  the  pulse  is  full 
and  strong,  hard  or  bounding,  and  there  is  severe  muscular  pain  in 
various  parts  of  the  body,  usually  involving  the  lumbar  and  pericra- 
nial  muscles ;  and  these  pains  persist,  though  not  so  severely,  during 
the  periods  of  remission. 

The  totigite  is  coated  heavily,  with  a  white  or  pasty- white  coat- 
ing, the  organ  is  broad  and  flabby,  and  there  is  a  putrefactive  odor 
about  the  breath. 


MALAEIAL  FEVEE :   TYPHO-MALARIAL  FORM. 


247 


In  three  or  four  days,  whether  antiperiodics  have  been  used  or 
not,  it  becomes  evident  that  the  patient  is  growing  weaker,  and  that 
there  is  no  progress  toward  recovery.  He  has  no  desire  to  get  out 
of  bed,  though  restless  and  uneasy,  and  there  may  be  delirium  at 
night.  The  chills  have  now  passed  away,  and  there  is  less  appear- 
ance of  a  remission  in  the  morning  than  at  first,  though  the  ther- 
mometer may  indicate  fully  as  much  decline  of  temperature.  There 
are  now  loathing  of  food,  thirst,  severe  muscular  pain,  and  marked 
restlessness.  The  tongue  begins  to  take  on  a  brownish  tinge  by  the 
end  of  the  first  week,  and  in  two  or  three  days  more  the  coating 
may  flake  off,  leaving  the  mucous  membrane  bare,  dark  red,  and 
slick — the  characteristic  beefsteak  tongue.  Or,  the  coating  may 
become  dry  and  brown,  and  gradually  wear  off  by  attrition,  the  beef- 
steak characteristic  not  appearing. 

Meantime,  as  the  disease  progresses,  the  patient  becomes  less 
restless,  the  night  delirium  passes  off,  and  a  condition  of  apathy  or 
drowsiness  comes  on,  the  patient  finally  becoming  somnolent,  and 
falling  into  a  profound  slumber  during  the  morning  remissions ;  and 


A 


TEMPERATUBE  CURVE  IN  TYPHO-MALABIAL  FEVER  (FATAL  CASE) 

soon  prolonged  sleep  comes  on,  the  skin  becomes  moist,  the  urine 
throws  down  a  copious  sediment,  and  convalescence  is  established 
between  the  fourteenth  and  twenty-first  day. 

In  the  nervous  class,  the  onset  is  not  so  abrupt  nor  severe, 
fever  comes  on  more  insidiously,  though  even  here  the  periodi. 
of  malaria  is  manifested.     The  pulse  is  small  and  rapid,  compr< 
sible,  or  wiry.     Prostration  is  evident  early,  and  is  more  marked  than 
in  the  septic  class,  though    the   patient   does  not   seem    to   suffer 


248  SPECIFIC  INFECTIOUS  DISEASES. 

severely.  The  tongue,  instead  of  being  large  and  broad,  is  narrow 
and  contracted,  tremulous  on  protrusion,  and  often  pointed,  and  red- 
dened at  the  tip  and  edges,  in  which  case  there  is  constant  nausea 
and  loathing  of  food,  and  sometimes  vomiting  upon  the  taking  of 
even  fluids,  with  provoking  thirst.  The  tongue  becomes  dry  and 
brown  early,  in  many  cases,  though  it  may  remain  moist  throughout. 
A  thin  white  coatiug  may  be  present  along  the  center  of  the  organ, 
but  it  soon  becomes  clean  and  slick,  or  the  coating  becomes  shriv- 
eled and  brown. 

Restlessness  is  a  marked  feature  of  this  condition,  and  the  patient 
is  delirious  at  night,  sometimes  actively  so,  and  the  condition  is 
very  much  aggravated  by  quinine  or  opiates. 

The  skin  is  dry  and  harsh,  the  secretions  generally  are  arrested, 
the  urine  being  scanty  and  high  colored,  and,  when  becoming  more 
profuse  at  the  end  of  the  fever,  it  throws  down  a  copious  sediment. 

Another  form  of  the  nervous  variety  is  the  comatose  form.  In 
this,  the  subject  becomes  comatose  within  a  day  or  two  after  the 
attack  begins,  there  being  complete  prostration  of  all  the  voluntary 
forces.  There  are  mouth-breathing,  brown  tongue,  dilatation  of  the 
pupils,  involuntary  evacuation  of  urine,  and,  in  some  cases,  apparent 
paralysis  of  the  extremities,  though  motion  returns  in  a  few  days, 
when  favorable  symptoms  succeed.  The  temperature,  in  this  form,  is 
not  remittent  to  any  marked  degree,  the  curve  resembling  that  of 
typhus  fever.  Within  a  few  days,  in  favorable  cases,  the  remissions 
become  more  marked,  and  the  patient  rouses  from  his  lethargy,  and 
passes  through  conditions  already  described. 

Typho-malarial  fever,  occurring  during  the  heated  term,  may 
take  on  intestinal  irritation,  and  develop  diarrhoea  or  dysentery;  or, 
if  bunglingly  treated  with  cathartics  in  the  start,  it  may  develop 
such  symptoms  at  any  time;  but  when  properly  managed,  the  bow- 
els are  not  usually  seriously  disturbed,  without  the  operation  of  some 
special  provoking  cause. 

Diagnosis. — The  absence  of  the  severe  abdominal  complica- 
tions of  typhoid  fever,  and  the  isolated  character  of  the  attacks,  will 
exclude  this  disease  from  the  diagnosis.  The  delirium  is  not  so 
severe  nor  so  obstinate  to  treat  as  that  of  typhus,  and  the  former 
history  of  the  case  will  usually  enable  the  practitioner  to  discrimi- 
nate between  them.  Cerebro-spinal  fever  often  takes  on  similar 
symptoms,  but  the  severe  muscular  pains  of  cerebro-spinal  fever,  the 
retraction  of  the  head,  and  the  irregular  course  of  the  fever,  will 
usually  declare  the  character  of  that  disease.  It  will  hardly  ever 
be  confounded  with  pernicious  malarial  fever,  for  the  reason  that 
that  disease  usually  occurs  in  southernlat  itudes,  while  this  is  a 
disease  of  temperate  regions. 


MALAEIAL  FEVER:   TYPHO-MALARIAL  FORM.  249 

Prognosis. — There  are  very  few  fatalities  attending  this  dis- 
ease, when  proper  therapeutic  means  are  employed  from  the  begin- 
ning. Though  a  disease  of  grave  aspect  in  the  early  part  of  its 
course,  rational  treatment  will  almost  invariably  bring  the  patient 
safely  through. 

Treatment. — One  rule  should  be  observed  in  the  treatment  of 
this  disease,  and  that  is,  to  refrain  from  attempting  to  break  it  up, 
as  though  it  were  a  case  of  ordinary  malarial  fever.  Heroic  doses 
of  quinine  should  be  left  out  of  the  treatment  altogether. 

In  the  septic  variety,  where  the  tongue  is  heavily  loaded  at  the 
base,  an  emetic,  administered  early,  may  lessen  the  severity  of  the 
conditions  which  follow,  and  also  prepare  the  system  for  the  better 
reception  of  other  remedies. 

The  broad,  flabby  tongue  will  call  for  one-grain  doses  of  sulphite 
of  sodium,  administered  every  two  or  three  hours,  until  the  peculiar 
coating  has  begun  to  disappear.  The  septic  condition  should  thus 
be  followed  with  the  appropriate  remedy  indicated  by  the  tongue, 
throughout  the  disease.  As  the  tongue  cleans  and  shows  the  beef- 
steak color  and  general  appearance,  muriatic  acid  will  be  the  proper 
corrective.  If,  instead  of  the  beefsteak  tongue,  the  coating  becomes 
browu,  with  tendency  to  the  deposit  of  sordes  on  the  teeth  and  lips, 
sulphurous  acid  will  be  more  proper. 

Where  muriatic  (hydrochloric)  acid  is  required,  we  will  prescribe 
as  follows:  R  Dilute  muriatic  acid  fi,  simple  syrup  or  water  fiii.  M., 
and  order  a  teaspoonful  every  three  or  four  hours.  Sulphurous  acid 
may  be  administered  in  twenty-drop  doses,  well  diluted,  every  two 
or  three  hours,  when  called  for  by  the  brown  coating  of  the  tongue. 

The  proper  antiseptic  should  be  accompanied  by  the  proper  sed- 
ative. With  the  full,  strong  pulse,  we  will  find  jaborandi  an  excel- 
lent remedy,  though  if  there  is  active  determination  of  blood  to  the 
brain,  as  indicated  by  the  bright  eyes,  contracted  pupils,  and  full, 
bounding  pulse,  gelsemium  may  be  combined  with  it  or  alternated 
advantageously.  ^  Jaborandi  jiii,  water  fiv.  M.,  and  order  a  tea- 
spoonful  every  hour.  Or,  R  Gelsemium  gtt  xx,  water  f  iv.  M.,  and 
order  a  teaspoonful  every  hour. 

The  sedative  mixture  should  be  administered  assiduously  until 
the  temperature  falls  and  signs  of  convalescence  appear.  Usually, 
as  the  disease  progresses,  the  sthenic  character  of  the  pulse  gives 
way  to  a  condition  of  lessened  force  in  the  impulse,  and  the  sedative 
may  properly  be  changed  to  small  doses  of  aconite  and  rlius  tox. 
For  example,  R  Lloyd's  aconite  gtt.  v-x,  rhus  tox.  gtt.  x-xv.,  water 
ziv.  M.,  and  order  a  teaspoonful  eveiy  hour.  Where  there  is  drow- 
siness, coldness  of  the  extremities,  dilated  pupils,  doughy  condition 


250  SPECIFIC  INFECTIOUS  DISEASES. 

of  the  tissues,  soft,  compressible  pulse,  and  other  indications  of 
feeble  capillary  circulation,  #  Belladonna  (specific  nn-dicine  or 
homeopathic  tincture)  gtt.  vi,  water  |iv.  M.,  and  order  a  teaspoon- 
ful  every  hour. 

If  there  be  intestinal  irritation,  with  diarrhoaa,  a  better  antiseptic 
than  the  sulphate  of  sodium,  sulphurous  acid,  or  muriatic  acid,  will 
be  echinacea  or  baptisia.  However,  if  there  be  the  marked  tongue 
indication  for  any  one  of  these  remedies,  it  should  have  the 
preference. 

The  nervous  type,  bearing  evidence  of  gastrio  irritation  by  the 
elongated  tongue,  with  restlessness,  will  call  for  aconite  and  rhus  tox., 
early.  R  Specific  aconite  gtt.  v,  specific  rhus  tox.  gtt.  x,  water  fiv. 
M.,  and  order  a  teaspoonful  every  hour.  This  will  constitute  the 
treatment  for  several  days,  until  all  evidence  of  gastric  irritation  has 
passed  away.  As  the  beefsteak  tongue  appearance  comes  on,  the 
preparation  of  muriatic  acid  already  described  may  be  made  use  of, 
in  connection  with  the  sedative  mixture  of  aconite  and  rhus  tox., 
which  must  be  continued  as  long  as  the  thermometer  indicates  the 
presence  of  febrile  action.  Sometimes  the  tongue  will  suggest  sul- 
phurous acid  instead  of  muriatic,  and  sometimes  echinacea  or  bap- 
tisia will  be  more  effective,  the  indications  for  these  remedies  not 
being  so  marked,  but  the  typhoid  condition  suggesting  some  agent 
of  antiseptic  character. 

The  treatment  already  suggested  will  apply  to  the  comatose  vari- 
ety, belladonna,  aconite  and  rhus  tox.  being  most  applicable.  Ech- 
inacea will  be  an  especially  excellent  antiseptic  here,  though  where 
there  are  prominent  indications  for  others,  it  should  not  be  used  to 
their  exclusion. 

Quinine  should  be  omitted  until  convalescence  sets  in,  and  then 
be  administered  in  small  doses,  if  at  all.  Better  remedies  here 
are  arseniate  of  quinia  3x,  or  tea-  or  fifteen-drop  doses  of  a  reliable 
fluid  preparation  of  grindelia  squarrosa. 

Daring  the  height  of  the  fever,  the  surface  should  be  sponged 
with  alkaline  tepid  water  each  day,  as  it  contributes  to  the  rest  and 
comfort  of  the  patient,  as  well  as  assisting  the  natural  efforts  to 
throw  off  the  fever. 

The  diet  should  be  similar  to  that  of  typhoid  fever,  liquid  in 
character,  though  solid  food  may  be  resumed  within  a  much  shorter 
time.  Milk,  malted  milk,  gruels,  etc.,  avoiding  fruits,  may  consti- 
tute the  food  for  the  term  of  fever,  the  patient  being  fed  regularly, 
as  a  supporting  regimen  now  seems  important,  to  encourage  ready 
recuperation. 


MALARIAL  FEVER  :    CHRONIC  FORM.  261 

CHBONIG  MALARIAL  FEVER. 

Synonym. — Malarial  Cachexia. 

Definition. — A  chronic  malarial  manifestation,  characterized  by 
anaemia,  sallow,  waxy  pallor  of  the  skin,  and  splenic  enlargement, 
with  attendant  indigestion,  debility,  languor,  and  other  malarial 
manifestations. 

Etiology. — This  condition  may  arise  from  repeated  attacks  of 
acute  malarial  disease,  or  it  may  come  on  gradually,  as  the  result  of 
long-continued  latent  malarial  poisoning. 

Pathology. — The  morbid  results  of  this  condition  differ  from 
those  of  malarial  fever  principally  in  extent.  The  spleen  seems  to 
be  the  part  which  suffers  the  most  anatomical  change.  It  is  very 
much  enlarged,  sometimes  filling  nearly  the  entire  abdominal  cavity, 
and  often  being  ten  or  twelve  times  its  normal  size,  tough,  firm,  and 
resistant.  The  capsule  is  thickened  and  uneven,  and  there  may  be 
adhesions  to  adjacent  structures.  There  is  marked  pigmentation 
throughout  the  entire  organ,  and  hyperplasia  or  degenerative  changes 
have  left  their  evidences  in  the  structures.  The  liver  and  kidneys 
are  similarly  altered,  though  not  so  prominently  so  as  the  spleen. 
The  blood-changes  are  not  so  marked  as  in  the  various  forms  of 
malarial  fever,  but  its  impoverished  condition  is  manifested  by  ten- 
dency to  dropsical  effusions  into  the  cellular  tissues  and  serous  cav- 
ities. Fibrinous  coagula  are  sometimes  found  in  the  arteries,  and 
cavities  of  the  heart  The  plasmodium  of  Laveran,  it  is  asserted, 
is  found  in  the  blood,  the  crescentric  form  being  the  most  common. 

Symptoms. — Malarial  cachexia  furnishes  us  with  a  great  vari- 
ety of  symptoms,  but  there  is  such  a  sameness  in  the  pathological 
conditions  resulting  in  different  cases,  that  a  rational  treatment  is 
suggested  as  applying  to  the  class  of  cases,  and  this  need  not  vary 
so  widely  in  individuals  as  might  at  first  be  supposed.  The  sub- 
jective symptoms  are  legion.  Sometimes  they  are  those  of  a  chronic 
intermittent,  with  rather  erratic  manifestation  of  the  paroxysms, 
these  being  attended  by  unusual  symptoms  of  prominence,  such  as 
a  neuralgic  manifestation, — periodical  tic  douloureux,  sciatica,  pleu- 
roclynia — and  sometimes  by  extreme  gastric  or  intestinal  disturbance, 
hemicrania,  etc.  In  other  cases,  the  ague  type  will  not  be  manifest 
at  all,  and  it  may  be  difficult  to  detect  any  .evidence  of  periodicity  in 
the  case,  unless  some  acute  aggravation  arises. 

In  all  cases,  there  is  prominent  evidence  of  disturbance  of  the 
assimilative  and  reconstructive  processes.  The  complexion  presents 
us  with  a  sallow,  waxy  pallor,  characteristic  and  striking;  the  patient 
is  debilitated  and  enervated;  palpitation  of  the  heart  attends  and 
follows  slight  exertion;  digestion  is  feeble;  the  bowels  are  usually 


252  SPECIFIC  INFECTIOUS  DISEASES. 

constipated;  the  skin  is  dry  and  harsh;  the  tissues  flabby  and  illy 
nourished;  the  tongue  broad,  flabby,  and  covered  with  a  pasty  white 
coating. 

There  will  be  found  upon  inspection,  a  fullness  of  the  abdomen 
over  the  epigastric  and  hypochondriac  regions,  the  lungs  being 
crowded  upward,  and  respiration  being  stuffy  and  difficult.  Some- 
times there  are  decidedly  asthmatic  symptoms  as  a  result  of  the  pres- 
sure from  splenic  and  hepatic  engorgement.  Hepatic  engorgement 
is  so  common  that  icteric  symptoms  are  often  more  or  less  manifest, 
in  many  cases. 

Perversion  of  the  sensibility  of  the  cutaneous  nerves  is  a  symp- 
tom which  is  not  uncommon.  I  have  seen  a  few  cases  where  the 
entire  scalp  seemed  cold  to  the  patient,  though  not  to  the  touch  of 
the  observer,  and  remained  so  for  months — until  restored  by  elec- 
tricity and  vapor  baths.  In  other  cases,  there  may  be  tingling  and 
numbness  in  some  portion  of  the  cutaneous  surface,  notably  that 
upon  the  outside  of  the  thighs.  Whether  this  is  alone  the  result  of 
malaria  or  of  the  abuse  of  quinine  and  calomel  is  not  quite  clear  to 
my  mind,  but  it  usually  occurs  in  those  who  have  been  subject  to 
old  orthodox  allopathic  treatment  for  a  considerable  length  of  time. 

A  certain  class  of  symptoms  is  always  present:  more  or  less  ver- 
tigo, tinnitus  aurium,  anorexia,  nausea,  and  difficult  digestion.  The 
patient  wakes  in  the  morning  with  a  foul  metallic  taste,  dizziness, 
sense  of  confusion  in  the  head,  and  general  soreness  and  stiffness. 
Myalgic  pains,  with  stiffness  of  the  muscles,  are  common  in  this  con- 
dition, and  there  is  frequently  a  sense  of  weariness,  constantly  pres- 
ent, with  nocturnal  wakefulness. 

Catarrhal  symptoms  are  not  uncommon,  these  manifesting  them- 
selves in  a  catarrhal  bronchitis,  or  in  the  form  of  muco-enteritis. 
Hemorrhages,  such  as  epistaxis,  hematuria,  menorrhagin,  and  even 
hemoptysis,  may  originate  as  a  symptom  of  malarial  infection.  Stub- 
born menorrhagia,  occurring  in  malarious  districts,  may  sometimes 
be  cured  with  means  directed  to  the  relief  of  malaria,  when  appar- 
ently more  rational  measures  fail 

Diagnosis. — The  existence  of  malarial  surroundings,  and  the 
fact  that  the  patient  has  been  exposed  to  their  influence  for  a  long 
time,  connected  with  the  fact  that  there  is  anaemia,  without  any 
other  known  cause,  will  suggest  malarial  cachexia.  Enlargement  of 
the  spleen  will  add  testimony  to  this  supposition.  Exclusion  of  seri- 
ous renal  affections  will  be  made  by  urinary  analysis,  and  careful 
palpation  will  serve  to  exclude  hepatic  cirrhosis.  Periodical  man- 
ifestations will  add  to  the  testimony  of  malarial  origin.  Microscop- 
ical examination  by  competent  observers  will  probably  detect  the 


MALARIAL  FEVER:   CHRONIC  FORM.  253 

hematozoa  of  Laveran;  however,  few  practitioners  will  need  to  go 
thus  far  in  order  to  render  a  correct  diagnosis,  even  provided  they 
possess  the  necessary  apparatus.  Another  condition  liable  to  be 
confounded  with  malarial  cachexia  is  leukaemia,  in  which  there  are 
enlargement  of  the  spleen  and  anaemia.  Here,  however,  there  is  great 
increase  in  the  proportion  of  white  blood-globules,  and  treatment 
for  malarial  cachexia  produces  no  effect.  As  leucocythsemia  is  usu- 
ally a  fatal  disease,  and  treatment  for  malarial  cachexia  could  not 
damage  the  patient,  a  mistake  of  this  kind  would  not  be  serious,  at 
any  rate. 

Prognosis. — The  prognosis  will  depend  largely  on  the  care  and 
attention  paid  to  the  management  of  the  case.  "When  possible 
to  remove  the  patient  from  malarious  surroundings  to  a  higher 
and  more  healthy  neighborhood  for  a  few  months,  a  much  more 
speedy  recovery  will  probably  follow.  Advanced  stages  which  have 
gone  on  to  structural  changes  in  the  spleen  with  amyloid  or 
melanotic  degeneration  and  effusion  into  the  serous  cavities,  are 
unpromising.  A  large  majority  of  the  cases,  however,  may  be  con- 
sidered favorable,  under  the  treatment  here  suggested. 

Treatment. — There  seem  to  be  rational  propositions  afforded, 
by  the  symptoms  and  pathology  of  this  disease,  for  a  direct  and  suc- 
cessful treatment.  However,  each  case  of  disease  will  always  be  an 
individual  one,  and  no  routine  treatment  need  be  expected  to 
invariably  succeed.  But  one  condition  is  always  present  here,  viz., 
splenic  congestion.  It  would  almost  seem  that  the  cachexia  really 
hinged  upon  this  condition,  the  congestion  being  the  precursor  of 
the  anaemic  state.  What  little  knowledge  of  the  functions  of  the 
spleen  we  possess  would  naturally  lend  color  to  this  proposition.  If 
the  splenic  congestion  could  be  averted  in  the  start,  it  is  probable 
that  the  cachexia  would  never  result,  the  other  complications  follow- 
ing as  sequelae  of  obstruction  to  important  circulatory  channels  and 
necessary  blood-making  functions. 

The  proposition  resolves  itself  then  into  the  treatment  of  a  case 
of  chronic  (but  ordinarily  curable)  splenic  congestion,  with  attendant 
incidental  complications.  Fortunately,  the  Eclectic  materia  medica 
contains  a  goodly  list  of  remedies  which  are  potent  in  curing 
splenic  congestion.  Carduus  marianus,  ceanothvs,  grinddia  sqnarrosa, 
and  polymnia  uvedcdia,  all  possess  particular  merit  in  this  direction, 
and,  equipped  with  them,  we  are  prepared  to  attack  the  disease  at 
its  very  foundation.  The  leading  proposition  throughout,  then,  will 
be  to  promote  normal  splenic  function,  and  preserve  a  free  portal 
circulation  by  the  aid  of  one  or  all  of  these  remedies.  This  accom- 
plished, the  remaining  part  of  the  task  will  not  be  difficult  There 


254  SPECIFIC  INFECTIOUS  DISEASES. 

is  such  a  similarity  in  the  action  of  these  remedies  that  it  will  not 
be  easy  to  always  discriminate  and  select  the  one  best  adapted  to 
au  individual  case.  However,  there  are  some  leading  points  which 
it  may  be  well  to  consider.  In  many  cases  the  combination  of  two 
or  more  of  them  may  afford  better  satisfaction  than  the  use  of  a  sin- 
gle one. 

Carduus  marianus  is  adapted  to  the  treatment  of  rather  recent 
cases,  in  which  there  is  a  mental  complication  bordering  on  hypo- 
chondriasis ;  the  patient  is  low  spirited,  and  inclined  to  melancholy. 
Where  this  is  a  prominent  characteristic  of  the  disease,  no  question- 
ing will  be  necessary  to  bring  the  symptom  out;  it  will  be  manifest 
upon  all  occasions.  Here,  carduus  is  the  remedy  for  first  choice 
Obscure  pains  in  the  pectoral  region  or  other  part  of  the  thorax,  as 
under  the  left  scapula,  would  also  suggest  carduus. 

A  prominent  indication  for  ceanothus  is  pain  in  the  spleen.  With 
marked  splenic  enlargement  attended  by  much  pain,  it  should  have 
the  preference  over  others  of  its  class,  as  a  rule,  though  there  is  no 
objection  to  rotation  of  the  others  where  this  fails.  However,  we 
are  here  prescribing  something  that  is  very  direct,  and  there  is  little 
probability  of  failure  if  a  proper  diagnosis  has  been  made. 

Painless  enlargement  of  the  spleen  may  be  taken  as  an  indication 
for  the  use  of  polymnia.  And  here  it  is  well  to  make  avail  of  the 
external,  as  well  as  the  internal,  use  of  the  drug.  The  polymnia 
ointment  here  comes  into  use,  it  being  applied  over  the  enlarged 
organ,  and  rubbed  in  with  plenty  of  friction.  Dyspeptic  complica- 
tion of  marked  character  is  another  indication  for  polymnia,  such  as 
burning  in  the  stomach  after  eating,  or  fullness  and  distension  with 
gases,  attended  by  difficult,  sighing  respiration.  This  comes  very 
near  the  condition  characterized  as  "prsecordial  oppression,"  a  symp- 
tom also  suggesting  polymnia  in  this  disease,  though  not  excluding 
the  others,  should  this  fail. 

Grindelia  squarrosa  has  not  been  tried  as  thoroughly  as  the  three 
already  canvassed.  There  may  be  obscure  cases,  not  very  well 
marked,  where  this  will  do  better  than  any  other  remedy.  It  has 
relieved  splenic  pain  and  dyspeptic  symptoms  of  long  standing  for 
me  very  satisfactorily  in  several  cases,  and  I  should  expect  much 
from  it  in  any  case  of  splenic  enlargement  in  maltrrial  cachexia.  It 
needs  more  study  to  fix  a  place  for  it.  As  we  do  not  object  to  a 
reasonable  amount  of  combination,  two,  three,  or  all  these  remedies 
may  be  combined  occasionally,  though  usually  I  would  not  expect  as 
prompt  results  as  where  a  proper  selection  had  been  made  of  one  or 
two  of  them. 

A  natural  sequence  of  splenic  congestion  is  hepatic  disturbance, 


MALARIAL  FEVER:    CHRONIC  FORM.  255 

of  greater  or  less  severity.  Sometimes  this  amounts  to  congestion 
of  the  liver,  announced  by  enlargement,  with  tenderness  on  pressure. 
In  other  cases,  there  may  only  be  functional  inactivity.  In  either 
case  icteric  symptoms  are  likely  to  be  more  or  less  manifest.  Con- 
gestive hepatic  disturbance  will  suggest  the  use  of  chelidonium,  in 
combination  with  the  appropriate  spleen  remedy;  hepatic  torpor 
without  congestion  will  properly  be  met  with  chionanthus.  Cheli- 
donium should  not  be  given  in  more  than  two-  or  three-drop  doses, 
repeated  four  times  daily;  chionanthus  may  be  given  in  ten-drop 
doses,  at  about  the  same  intervals.  A  good  method  would  be  to  com- 
bine the  spleen  and  liver  remedies  in  the  same  dose. 

Often  the  stomach  will  be  found  to  give  rise  to  the  most  promi- 
nent symptoms.  "We  have  the  torpid  stomach,  where  the  tongue  is 
heavily  coated  at  ihe  base,  and  where  there  seems  to  be  a  morbid 
accumulation  in  the  viscus,  as  suggested  by  eructation  of  gases,  diffi- 
cult digestion,  etc.  When  this  condition  is  present  it  will  be  found 
a  persistent  one,  and  its  removal  will  become  an  important  matter. 
The  treatment  here  is  the  administration  of  emetics,  repeated  once  or 
twice  a  week,  until  the  eructations  have  ceased,  and  the  tongue  has 
assumed  a  normal  condiiion.  I  usually  employ  powdered  ipecac,  giv- 
ing from  three  to  five  grains,  stirred  in  half  a  cup  of  hot  water, 
repeating  every  ten  minutes,  until  free  emesis  follows.  It  is  well  to 
order  an  extra  teacupful  of  hot  water  between  the  doses.  In  other 
cases,  the  tongue  will  be  broad  and  flabby,  and  evenly  coated  with  a 
dirty,  pasty  white  coating.  This  is  also  a  persistent  symptom,  and 
must  be  removed,  in  order  that  the  patient  may  make  rapid  prog- 
ress. "We  expect  to  correct  this  with  sulphite  of  sodium',  dose,  a 
grain,  in  capsule,  four  timas  daily,  continued  until  the  coating  has 
disappeared.  Gastric  irritation  is  another  symptom  that  sometimes 
demands  attention,  though  it  is  not  common  in  malarial  cachexia. 
It  is  recognized  by  the  pointed  tongue,  with  reddened  tip  and  edges, 
accompanied  by  vomiting,  and  disgust  for  food.  "We  remedy  this  by 
using,  for  several  days,  a  mixture  of  five  or  eight  drops  of  aconite 
with  twenty  drops  of  rhus  tox.,  in  four  ounces  of  water;  dose,  a  tea- 
spoonful  every  one  or  two  hours.  Meantime,  our  spleen  remedies 
should  be  steadily  administered,  whatever  other  treatment  may  be 
indicated. 

Normal  activity  of  the  general  circulation  is  an  important  consid- 
eration, whatever  the  condition  may  be.  Even  splenic  congestion 
may  be  reached  by  a  method  which  will  provide  for  a  vigorous  cut;t« 
neous  capillary  circulation.  The  vapor  bath,  either  the  alcoholic,  or, 
what  is  preferable,  the  steam  cabinet  bath,  is  an  admirable  remedy 
in  chronic  malarial  poisoning.  It  very  materially  assists,  and  is  even 


256  SPECIFIC  INFECTIOUS  DISEASES. 

capable  of  curing  most  cases,  unaided  by  other  means.  When  prac- 
ticable— where  the  means  are  at  hand — a  steam  cabinet  bath  may 
be  taken  every  other  day  for  a  fortnight,  and  afterward  twice  a  week, 
until  recovery  has  been  fully  established.  This  does  not  interfere 
with  other  treatment  and  is  a  powerful  adjuvant,  to  say  the  least  of  it. 
The  gastric,  hepatic,  and  splenic  symptoms  yield  to  it  speedily,  and 
digestion  and  assimilation  are  speedily  restored  to  a  normal  condition. 
The  baths  may  be  much  aided  by  using,  in  conjunction  with  them, 
the  tonic  faradic  treatment  described  in  Dynamical  Therapeutics. 

Some  authors  advise  the  removal  of  the  patient  to  a  non-mala- 
rious district.  This  is  good  advice,  but,  unfortunately,  a  large  per- 
centage of  these  patients  are  not  financially  able  to  incur  the  expense 
of  such  a  change.  We  must  be  able  to  do  better  than  choose  one  of 
these  alternatives — sending  them  away,  or  leaving  them  at  home 
to  die. 

We  do  not  want  much  quinine  in  the  treatment  of  these  cases. 
We  will  find,  if  we  make  the  trial,  that  they  have  worn  quinine  out 
— that  this  drug  aggravates  instead  of  ameliorating.  If  there  is 
periodicity  and  quinine  is  administered  for  its  interruption,  no 
impression  will  be  made,  usually.  It  is  not  impossible  that  malarial 
cachexia  may  really  be  largely  chronic  quinine  poisoning.  At  least 
that  drug  bears  the  reputation  of  producing  portal  congestion,  and 
in  this  case  such  a  condition  is  just  what  we  are  endeavoring  to  get 
rid  of.  Alstonia  and  arseniate  of  quinia,  in  alternation,  are  more  effec- 
tive here,  and  less  objectionable.  As  a  steady  tonic  here,  when  I 
desire  to  employ  an  anti-malarial  agent-,  I  prescribe  the  following 
capsule:  R  Alstonia  constricta  gr.  iii,  arseniate  of  quinia,  3x  trit, 
gr.  ii  M.,  and  fill  one  capsule.  Duplicate  No.  30.  S,  One  after 
each  meal. 

Since  the  foregoing  was  written,  I  have  given  especial  attention 
to  grindelia  squarrosa,  as  a  general  curative  agent  in  chronic  malarial 
cachexia.  A  careful  review  of  Prof.  Bundy's  writings,  and  an  inves- 
tigation of  some  of  his  arguments  as  to  unreliability  of  preparations 
of  this  agent  often  found  in  the  market,  with  subsequent  extended 
use  of  a  tincture  prepared  by  myself  from  the  recent  plant,  have  con- 
vinced me  that  this  is  the  best  remedy  we  possess  for  the  cure  of 
malarial  cachexia.  I  will  premise  quotation  of  what  Prof.  Bundy 
has  written  upon  the  subject,  by  asserting  it  as  my  b  -lief,  that  he 
has  not  overestimated  the  value  of  this  remedy,  and  that  when  a 
reliable  preparation — one  true  to  name — is  employed,  it  will  seldom 
prove  disappointing.  Following  is  the  quotation  with  reference 
to  the  subject,  from  Prof.  Bundy's  pen: 

"The  continuance  of  chronic  intermittents  is  most  frequently  the 


MALARIAL  FEVER:    CHRONIC  FORM.  257 

result  of  splenic  hypertrophy.  The  hypertrophy  is  a  secondary 
matter  at  first,  but  when  well  established  it  becomes  the  perpetuat- 
ing cause.  This,  I  am  satisfied,  is  a  fact,  and  so  long  as  the  hyper- 
trophy exists,  so  long  will  the  paroxysms  continue  to  return.  Qui- 
nine, arsenic,  picrate  of  ammonium,  etc.,  are  given  separately  and 
combined  in  every  conceivable  manner,  yet  the  paroxysms  appear 
every  eighth,  fifteenth,  or  twenty-second  day  for  months,  until  the 
patient  becomes  bloodless  and  reduced  to  a  mere  skeleton,  the  abdo- 
men distended  by  an  enlarged  spleen,  and  from  dropsical  effusion. 

"What  is  necessary  in  this  case  is  to  remove  the  splenic  hyper- 
trophy, which  is  positively  the  perpetuating  cause,  in  combination 
with  malarial  influences,  if  the  patient  lives  in  a  malarious  district. 
'  There  is  a  balm  in  Gilead,'  and  when  the  profession  has  frittered 
away  time  enough  in  'tinkering'  with  routine  and  hackneyed  treat- 
ment in  unsuccessful  attempts  to  cure  chronic  intermittents,  it  may 
see  fit  to  resort  to  this  remedy,  and  learn  how  to  succeed  in  curing 
them. 

"The  drug  is  grindelia  squarrosa.  I  have  cured  over  seventy 
cases  in  the  past  four  years,  and  I  have  yet  to  see  the  case  it  will 
not  cure  if  properly  given.  That  it  may  sometimes  fail  is  entirely 
possible,  as  almost  any  remedy  is  liable  to  sometimes  disappoint; 
but  failure  in  my  hands  in  curing  chronic  ague  has  never  occurred 
with  this  remedy. 

"My  last  case  is  that  of  a  child  18  months  old.  The  spleen  was 
four  times  the  natural  size,  and  this  condition  had  existed  seven 
months  when  I  commenced  treatment.  I  gave  R  Fluid  extract  of 
grindelia  squarrosa  (P.,  D.  &  Co.'s)  ^iii,  syr.  acacia  and  aqua  dest.  aa, 
fii.  Sig.,  a  teaspoonful  four  times  daily.  $  Tinct.  ferri.  chlor.  ?i, 
simple  syrup  fiii.  M.  Sig.,  one  teaspoonful  four  times  daily.  One 
prescription  was  given  before  and  the  other  after  meals.  From 
three  to  ten  weeks  of  this  treatment  may  be  necessary." 

Bundy  believed  that  there  was  a  great  deal  of  fluid  extract  of 
grindelia  squarrosa  in  the  drug  market  which  was  not  true  to  name, 
but  which  was,  instead,  fluid  extract  of  grindelia  robusta.  For  the 
two  varieties  resemble  each  other  very  much,  and  are  liable  to  be 
confounded  by  inexperienced  herb-gatherers.  This  may  explain  the 
failures  which  often  attend  the  use  of  this  remedy  in  the  treatment 
of  chronic  malaria.  From  extended  personal  experience  with  a  tinc- 
ture prepared  by  myself  from  the  recent  herb  gathered  near  Colusa, 
by  a  medical  gentleman  who  knew  Bundy  while  there,  I  am  con- 
vinced that  the  fluid  extract  of  Parke,  Davis  &  Co.,  labeled  grindelia 
squarrosa,  is  true  to  name,  and  I  am  doubtful  about  the  identity  of 
every  other  preparation  I  have  found  in  the  market. 


258 


SPECIFIC  INFECTIOUS  DISEASES. 


XXI.  ANTHRAX. 

Synonyms. — Malignant  Pustule;  Splenic  Fever;  Malignant 
(Edema;  "Wool-sorter's  Disease. 

Definition. — An  acute,  infectious  disease,  caused  by  the  bacil- 
lus anthracis,  characterized  by  destructive  inflammation  at  the  seat 
of  inoculation,  and  severe  constitutional  symptoms  of  grave  charac- 
ter, arising  therefrom. 

Etiology. — The  bacillus  anthracis,  the  active  principle  of  this 
disease,  was  the  first  specific  microbe  of  disease  detected  and 

described.  It  is  from  two  to 
three  times  the  diameter  of 
a  red  blood-corpuscle  in 

v^:  ;y^gg^s=- £j^'rz-    length,  the  rods  often  being 
&"CT  '''• v:'/',  f  E^X^J**^  ML  united.     It  multiplies  by  fis- 

-  fc^5«££5V  •*  ^5^     /j^^^xjgj 

*\^**^^'&*?*^  si°D>  anc*  Srows  verJ  rapidly 
^\V.'«fVa>^*  on    culture   medium,    the 

spores  possessing  remark- 
able vitality,  though  the 
bacilli  are  easily  destroyed. 
It  is  introduced  into  animal 
tissues  by  inoculation  from  the  bites  or  stings  of  insects,  into  the 
stomach  with  the  food,  and  into  the  lungs  through  inspired  air. 

It  is  a  malady  principally  infecting  cattle  and  sheep,  though  those 
of  the  human  family  who  are  about  and  .exposed  to  infected  animals 
and  animal  products,  are  most  liable  to  become  diseased.  Thus, 
butchers,  tanaers,  wool-sorters,  herdsmen,  etc.,  are  more  liable  to 
acquire  the  disease  than  ordinary  individuals. 

It  is  more  common  in  certain  parts  of  Europe  and  Asia  than  in 
this  country,  though  it  is  not  uncommon  in  South  American  cattle 
districts. 

When  a  region  becomes  infected,  the  bacillus  seems  to  be  perpet- 
uated for  a  long  time.  Pasteur  believed  that  the  bacilli  might  be 
brought  from  the  buried  carcass  of  an  infected  animal  to  the  surface 
by  earth-worms,  and  there  prove  a  source  of  infection  to  new  indi- 
viduals. Others  doubt  the  soundness  of  these  views,  though  they 
admit  the  persistency  of  the  infection,  in  regions  once  contaminated. 

It  will  be  described  under  the  following  heads : 

EXTERNAL  ANTHRAX. 

MALIGNANT  PUSTULE. — In  this  form  of  anthrax,  the  inoculation 
usually  occurs  upon  an  exposed  part,  such  as  the  face,  hands,  arms,  or 
neck,  arid  is  probably  due  to  the  bites  or  stings  of  insects.  The 
first  announcement  of  the  disease  is  a  small  papule,  though  its 


ANTHKAX.  259 

appearance  may  be  heralded  a  few  hours  by  burning  and  itching  in 
the  vicinity.  The  papule  enlarges  rapidly,  until  a  vesicle  appears 
upon  its  summit  and  a  hardened  areola  surrounds  its  base.  Within 
thirty-six  hours  a  brown  slough  appears  in  the  center,  denoting  the 
point  of  inoculation.  Numerous  vesicles  now  appear,  surrounding 
the  vicinity  of  this  point,  and  resembling  the  numerous  openings  of 
a  carbuncle.  The  local  inflammation  spreads  rapidly,  extreme  indu- 
ration and  swelling  speedily  appearing,  and  the  lymphatics  convey 
the  irritation  to  neighboring  glands,  which  become  swollen,  indu- 
rated, and  painful.  Constitutional  symptoms  soon  appear,  a  rapid 
rise  of  temperature  and  other  febrile  phenomena  being  afterward 
followed  by  subnormal  temperature,  coma,  and  death.  In  favorable 
cases,  the  constitutional  symptoms  are  not  SO  severe,  and  the  local 
symptoms  are  marked  by  sloughing  at  the  point  of  irritation,  with 
gradual  healing  of  the  cavity. 

MALIGNANT  (EDEMA.  —  This  occurs  in  parts  containing  a  large 
amount  of  connective  tissue,  and  which  are  liable  to  puffy  swelling 
under  other  circumstances,  such  as  the  eyelid,  head,  hand,  arm,  and 
other  parts.  There  is  here  an  absence  of  the  papule  and  vesicle, 

and,  when  sloughing  occurs,  a  large  sur- 
face  is  involved.  The  oedema  spreads 
rapidly,  involving  large  areas,  and  the 
constitutional  symptoms  are  almost 
always  extreme,  and  usually  lead  to  a 


or 
OQOB  M  A, 


The  character  of  the  lesion  —  its  prog- 
ress —  and  the  severe  constitutional  symptoms  which  attend,  in  addi- 
tion to  the  occupation  of  the  patient,  will  usually  afford  a  clear  diag- 
nosis, in  either  malignant  pustule  or  malignant  oedema.  Microscop- 
ical examination  of  the  fluid  of  the  affected  part  will  disclose  the 
presence  of  the  anthrax  bacilli. 

INTERNAL  ANTHEAX. 

MYCOSIS  INTESTINALIS.  —  This  form  arises  from  the  reception  of 
the  parasite  into  the  stomach  with  the  food,  when  the  flesh  of  dis- 
eased animals  is  eaten,  or  the  milk  of  affected  cows  is  drunk.  The 
symptoms  are  ushered  in  with  a  chill,  and  attended  by  severe  gastro- 
intestinal disturbance,  such  as  vomiting,  diarrhoea,  burning  pain  in 
the  stomach  and  intestines,  dyspnoea,  cyanosis,  and  extreme  restless- 
ness, followed  by  coma  or  convulsions.  This  form  of  the  disease 
usually  attacks  several  persons  simultaneously  —  those  who  have 
eaten,  at  the  same  time,  of  the  flesh  of  an  animal  affected  with 
anthrax. 


260  SPECIFIC  INFECTIOUS  DISEASES. 

WOOL-SORTER'S  DISEASE. — This  disease  arises  among  the  employes 
of  large  wool-  or  hair-sorting  establishments,  the  microbe  being 
inhaled  during  the  handling  of  the  diseased  material.  The  hair  and 
wool  imported  into  Europe  from  South  America  and  Russia  seem  to 
be  most  commonly  infected.  The  dust  arising  during  the  handling 
of  these  products  seems  to  contain  the  bacillus  anthracis,  at  least 
the  microbe  gains  entrance  to  the  interior  of  the  body  during  the 
commotion,  either  by  way  of  the  stomach  or  lungs,  and  serious 
symptoms  follow.  The  patient  is  attacked  with  a  chill,  followed  by 
fever,  attended  by  racking  pains  in  the  limbs  and  back,  short,  rapid 
breathing,  with  severe  pains  in  the  chest,  and  usually  signs  of  bron- 
chitis. Gastric  symptoms  often  supervene,  vomiting  and  purging 
attending,  and  rapid  prostration  follows.  Sometimes  there  is  delir- 
ium during  the  advanced  stage  of  the  disease,  and  sometimes  coma. 

The  diagnosis  in  such  cases  is  difficult,  and  can  only  be  inferred 
from  the  occupation  of  the  sufferer  and  the  violent  symptoms,  until 
investigated  from  a  bacteriological  standpoint. 

Treatment. — The  treatment  thus  far  followed  has  not  yielded 
a  great  amount  of  satisfaction.  It  is  advised  to  destroy  the  pustule 
by  tlie  use  of  actual  cautery  or  caustic  potash,  and  sprinkle  pow- 
dered bichloride  of  mercury  over  the  surface.  Subcutaneous  injec- 
tions of  carbolic  acid  about  the  pustule,  to  prevent  the  spread  of  the 
bacilli,  are  also  advised.  It  seems  to  me  that  such  treatment  can- 
not but  make  a  bad  matter  worse,  and  aggravate  the  whole  affair. 
Probably  echinacea  will  be  a  better  remedy,  both  internally  and 
locally,  the  system  being  saturated  with  it.  Lachesis  and  crolalus  hor. 
would  be  applicable,  also.  It  is  a  fact  that  heroic  treatment  often 
aggravates  diseases  which  it  is  intended  to  relieve,  and  this  is  likely 
to  be  one  of  the  instances. 

XXn.  HYDROPHOBIA. 

Synonyms. — Rabies;  Lyssa. 

Definition. — Hydrophobia  in  man  is  an  acute,  specific,  conta- 
gious, almost  invariably  fatal  disease,  due  to  an  unknown  microorgan- 
ism, and  transmitted  by  some  animal,  by  inoculation.  After  a  period 
of  incubation,  there  are  violent  spasms  of  the  muscles  of  deglutition 
and  respiration;  later,  general  convulsions,  great  prostration,  and 
finally  ascending  paralysis,  and  death. 

Etiology. — The  disease  is  principally  noticed  in  dogs  (90%), 
although  it  has  occurred  in  cats,  wolves,  foxes,  badgers,  martens, 
hyaenas,  jackals,  polecats,  horses,  asses,  mules,  oxen,  and  sheep. 

The  disease  is  common  in  Russia,  less  so  in  England  and  France, 
and  rare  in  Germany  and  America. 


HYDKOPHOBIA.  261 

It  is  produced  by  the  bites  of  animals  suffering  from  rabies,  or  by 
accidental  inoculation  of  wounds  with  their  saliva  or  blood,  the  lat- 
ter occurring  occasionally  iu  autopsies  of  infected  animals.  The 
virus  may  be  swallowed,  or  may  come  in  contact  with  the  unbroken 
skin,  without  developing  the  disease.  It  retains  its  vitality  some 
time  after  the  death  of  the  animaL  Communication  from  man  to 
man  is  defied.  The  consensus  of  opinion  seems  to  be  against  the 
spontaneous  origin  of  rabies  among  animals. 

All  persons  bitten  by  rabid  animals  do  not  contract  the  disease, 
the  percentage  of  cases  being  about  12  to  14  The  saliva  is  often 
prevented  from  gaining  entrance  to  the  wound  by  the  clothing.  In 
other  cases,  cauterizing  the  bite  destroys  the  virus.  Efforts  to  dis- 
cover the  microbe  which  produces  the  disease,  have  thus  far  failed. 

Pathology. — There  are  no  well-defined  pathological  changes. 
Rigor  mortis  is  marked,  and  decomposition  sets  in  early.  The  blood 
is  thin,  and  darker  than  usual.  The  blood-vessels  are  more  or  less 
congested,  excepting  those  of  the  heart,  spleen,  and  liver,  which 
are  normal,  as  a  rule.  The  pharynx  and  fauces  are  much  congested, 
the  same  condition  being  observed  in  the  mucous  membrane  of  the 
alimentary  and  respiratory  tracts.  The  brain  and  spinal  cord,  with 
their  membranes,  are  hyperaemic,  and  considerable  oedema  is  present 
Scattered  throughout  the  whole  central  nervous  system,  but  more 
noticeable  in  the  base  of  the  brain  and  spinal  cord,  there  are  patches 
of  inflammatory  deposit. 

Symptoms. — The  stage  of  incubation  is  much  longer  than  in 
most  of  the  infectious  diseases,  and  usually  lasts  from  two  to  six 
weeks;  rarely,  it  is  protracted  to  a  year  or  more.  The  wound  heals, 
if  sufficient  time  elapses,  and  the  patient's  health  is  about  as  usual. 
The  length  of  this  stage  is  influenced  by  the  age  of  the  individual, 
children  manifesting  symptoms  of  rabies  sooner  than  adults. 

From  one  to  three  days  before  the  serious  symptoms  develop, 
the  patient  has  more  or  less  constitutional  disturbance.  There  is 
headache,  anorexia,  insomnia,  a  feeling  of  dread  and  apprehension, 
and  a  general  hyperaesthesia.  The  countenance  has  a  look  of  anxiety, 
and  the  pupils  are  dilated.  There  may  be  pain  in  the  region  of  the 
wound,  with  more  or  less  tenderness  aud  congestion,  with  occasional 
suppuration.  Frequently,  all  local  symptoms  are  absent.  "We  now 
notice  more  or  less  respiratory  oppression.  There  is  difficulty  in 
enunciation  aud  deglutition,  caused  by  muscular  spasm,  and  a  sensa- 
tion of  choking  about  the  pharynx.  Water  is  refused,  on  account  of 
the  painful  spasmodic  condition  excited  in  the  throat.  There  is  an 
abundant  secretion  of  viscid  saliva,  which  cannot  be  swallowed,  and 
is  constantly  expectorated. 


262  SPECIFIC  INFECTIOUS  DISEASES. 

Respiratory  or  pharyngeal  phenomena  may  be  the  first  indication 
of  tin  approaching  attack,  other  premonitory  symptoms  being  absent. 

The  spasmodic  condition  at  length  begms  to  assume  a  serious 
phase,  and  the  patient  is  excited,  not  only  by  attempts  to  swallow, 
but  the  sight  of  water,  or  a  mere  suggestion  of  drinking,  producing  a 
convulsion.  General  hyperaBsthesia  develops  to  such  a  degree  that 
loud  sounds,  an  unexpected  touch,  currents  of  air,  bright  lights,  or 
the  contact  of  the  bedclothing,  is  sufficient  to  initiate  a  spasm. 
These  seizures  last  from  one-  to  three-quarters  of  an  hour,  and  leave 
the  sufferer  exhausted.  In  the  intervals,  his  mind  is  clear,  but  he  is 
tortured  by  apprehension  of  returning  attacks,  and  anticipations  of 
his  terrible  sufferings.  The  convulsive  action  that  was  first  confined 
to  the  respiratory  organs,  soon  becomes  general,  with  periods  of  hal- 
lucination and  mania,  due  to  excitement  and  partial  asphyxiation. 
The  mouth  and  fauces  are  dry,  and  there  is  a  constant  hawking  of 
adhesive  mucus  and  saliva,  which  are  expectorated  indiscriminately 
over  the  bed  and  attendants.  The  pulse,  which  was  at  first  normal, 
grows  weak  and  rapid,  and  the  temperature  rises,  raging  from  101°  to 
103°  F.  This  stage  of  the  disease  lasts  from  one  to  three  days,  and 
death  may  occur  from  exhaustion  or  asphyxia. 

Occasionally  there  are  no  convulsions,  the  patient  complaining 
principally  of  dyspnoea.  Some  few  are  enabled  to  swallow  through- 
out the  disease,  although  considerable  pain  accompanies  deglutition. 
There  is  now  a  gradual  transition  to  the  third  stage,  the  stage  of 
paralysis,  which  lasts  from  three  to  eighteen  hours.  The  prostration 
grows  more  marked,  and  there  is  a  diminution  of  convulsive  action. 
Respiration  is  much  easier,  and  the  spasmodic  condition  of  the  laryn- 
geal  muscles  is  diminished,  so  that  liquids  can  be  swallowed.  Rap- 
idly ascending  paralysis  commences,  and  respiratory  and  cardiac  fail- 
ure closes  the  scene. 

Diagnosis. — After  hydrophobia  has  fully  developed,  there  is  no 
possibility  of  a  mistake  in  diagnosis.  The  only  diseases  that  may 
simulate  it  are  lyssophobia  (hydrophobia  imaginary),  tetanus,  and 
cases  of  epilepsy  or  hysteria,  where  the  organs  of  deglutition  are 
affected.  In  rabies,  the  muscles  of  mastication  are  not  affected,  the 
convulsions  are  not  tonic,  and  the  apnoea  is  due  to  spasms  of  the  lar- 
yngeal  muscles  and  not  to  those  of  the  chest  Hysterical  persons 
sometimes  develop  symptoms  that  simulate  hydrophobia.  They 
imagine  they  have  the  disease,  and  have  paroxysms,  in  which  they 
refuse  to  drink,  grasp  the  throat,  and  manifest  more  or  less  violence 
iu  their  excitement.  There  is  no  elevation  of  temperature,  and  the 
hallucination  lasts  longer  than  true  rabies.  Probably  in  these  cases 
hypnotic  suggestion  could  be  successfully  used. 


HYDROPHOBIA.  263 

Treatment. — The  disease  once  established,  death  is  almost 
inevitable,  and  we  can  only  use  such  methods  as  will  modify  the 
severity  of  the  dying  struggle. 

Prophylaxis,  therefore,  assumes  great  importance,  and  all  suspi- 
cious cases  should  receive  prompt  attention.  The  physician  is  not 
called,  as  a  rule,  until  some  time  after  the  injury,  and  the  destruction 
of  the  lacerated  flesh  should  not  be  delayed.  If  chloride  of  zinc, 
caustic  potash,  or  concentrated  carbolic  acid  are  at  hand,  the  wound 
should  be  cauterized,  after  being  carefully  washed.  If  there  is  likely 
to  be  any  delay  in  procuring  the  cauterizing  agent,  the  flesh  that  has 
coma  in  contact  with  the  teeth  should  be  excised,  the  knife  cutting 
wide  of  the  wound.  It  is  advisable  to  apply  a  cup,  and  favor  hem- 
orrhage. The  actual  cautery,  while  severe,  is  efficient.  The  wound 
should  be  kept  open  for  at  least  a  month.  If  there  is  any  doubt 
about  the  dog  having  hydrophobia,  it  should  be  kept  penned  up  a 
sufficient  time  to  develop  the  disease.  When  the  animal  is  not  mad, 
the  patient  may  thus  be  saved  weeks  of  useless  apprehension  and 
mental  suffering. 

The  discovery  of  preventive  inoculation,  by  Pasteur,  created  quite 
a  furor,  and  institutions  for  the  treatment  of  rabies  have  been 
founded  in  various  parts  of  the  Old  World.  Pasteur  found  that  the 
virus  increased  in  potency  when  a  number  of  rabbits  were  success- 
ively inoculated,  so  that  when  this  more  virulent  product  was  used, 
only  seven  days  elapsed  before  the  symptoms  of  hydrophobia  devel- 
oped, whereas  fifteen  were  required  in  the  primary  inoculation.  The 
virus  is  taken  from  the  spinal  cord  of  the  rabbit,  and  it  was  discov- 
ered that  it  gradually  decreased  in  intensity  when  the  cords  were 
preserved  in  dry  air.  A  dog  was  now  inoculated  with  virus  twelve 
or  fifteen  days  old,  and  the  process  was  repeated  with  stronger  solu- 
tions, until  it  was  found  that  he  had  acquired  immunity  from  the 
disease,  and  that  the  most  potent  virus  had  no  effect  upon  him.  In 
his  treatment  of  patients,  Pasteur  used  virus  of  greater  intensity 
011  successive  days,  and  claimed  to  be  able  to  abort  the  disease  when 
the  patient  was  seen  early  enough.  Much  doubt  exists,  however, 
with  regard  to  the  efficacy  of  Pasteur's  methods. 

In  former  times,  the  unfortunate  who  developed  rabies  was 
smothered  between  two  mattresses;  and,  although  the  practice  seems 
barbarous,  it  was  undoubtedly  humane. 

All  treatment  fails  to  check  the  course  of  the  disease,  so  our 
attention  is  directed  toward  alleviating  the  suffering  of  the  patient. 
Ha  should  be  removed,  by  his  attendants,  to  a  dark  room.  Chloro- 
form anaesthesia,  an  I  narcosis  by  hypodermic  injection  of  morphine, 
are  carried  to  extreme  length,  all  milder  agents  being  discarded  as 


264  SPECIFIC  INFECTIOUS  DISEASES. 

useless.  Cocaine,  applied  to  the  throat,  will  diminish  the  hyperses- 
thesia,  and  permit  of  liquids  being  taken.  Death  occurs  in  from  two 
to  ten  days.  lu  rare  cases,  patients  may  survive  for  three  weeks. 
Curare,  amyl  nitrite,  and  nitro-glycerine,  recommended  in  the  article 
on  tetanus,  may  be  tried,  but  reported  cures  are  open  to  suspicion. 

Professor  Goss  asserts  that  echinacea  exerts  a  prophylactic  influ- 
ence, when  administered  steadily  after  the  period  of  inoculation,  in 
fifteen-  or  twenty-drop  doses,  repeated  four  or  five  times  daily. 

Cures  have  been  reported  from  the  inhalation  of  oxygen  gas,  after 
the  spasmodic  symptoms  have  appeared. 

XXIII.    TETANUS. 

Synonyms. — Lock-jaw ;  Trismus. 

Definition. — Tetanus  is  an  acute  or  chronic  infectious  disease, 
characterized  by  a  progressive  tonic  spasm  of  the  voluntary  muscles, 
with  paroxysmal  exacerbations,  resulting,  as  a  rule,  in  death.  It 
may  occur  in  epidemic  form  among  the  wounded,  in  times  of  war,  or 
in  children,  in  lying-in  hospitals. 

Pathology. — Where  pathological  lesions  are  present,  they  are 
secondary,  and  dependent  on  the  excessive  muscular  spasm,  the  pri- 
mary disturbance  being  reflex  and  functional.  Occasionally  the 
nerves  supplying  the  affected  parts  show  inflammatory  changes. 
The  spinal  cord  and  medulla  are  at  times  hypersermic,  and  there  may 
be  effusions  and  more  or  less  extravasation. 

Etiology. — Tetanus  is  due  to  the  bacillus  tetani,  which  gains  an 
entrance  into  the  body  through  a  traumatism.  The  old  division  of 
the  disease  into  traumatic  and  idiopathic  tetanus 
is  questioned  by  modern  authorities,  and  all 
cases  are  believed  to  be  due  to  an  injury  of  some 
character. 

The  baviUus  tetani  is  short  and  straight,  with 
an  enlargement  at  one  end,  due  to  sporulation. 
Several  ptomaines  are  derived  from  it,  and  it  is 
believed  that  the  irritation  of  the  nervous  sys- 
tem is  mainly  due  to  their  presence,  as  but  few  of  the  bacilli  are  to 
be  seen  in  the  body.  The  spores  are  to  be  found  in  manure,  garden 
soil,  decomposing  liquids,  masonry,  and  the  dust  of  streets.  It  is 
anaerobic. 

Tetanus  may  follow  injuries  of  most  any  kind,  such  as  wounds, 
burns,  fractures,  or  dislocations.  It  has  occurred  after  abortion,  and 
normal  labor.  Surgical  operations,  such  as  the  ligation  of  piles, 
amputations,  castration,  or  even  the  passage  of  uterine  sounds,  have 


TETANls  265 

been  followed  by  lock-jaw.     In  infants,  the  bacilli  gain  an  entrance 
through  the  navel. 

A  rare  case  has  been  reported,  where  the  disease  was  due  to  an 
accumulation  of  bird-shot  in  the  appendix  vermiformis.  Where  teta- 
nus follows  a  simple  fracture  or  dislocation,  the  disease  is  supposed 
to  be  due  to  internal  infection.  Telluric  conditions  are  believed  to 
have  much  to  do  with  the  development  of  tetanus.  It  is  more  fre- 
quently met  with  in  hot  climates.  It  has  been  frequently  noticed 
that,  after  battles,  sudden  changes  of  temperature  have  been  fol- 
lowed by  the  development  of  many  cases  of  this  disease  among  the 
wounded.  While  no  age  or  sex  is  exempt,  adult  males  furnish  the 
greater  number  of  cases. 

Symptoms. — The  stage  of  incubation  is  variable  in  length,  but 
it  generally  lasts  about  a  week. 

The  patient  first  notices  a  stiffness  in  the  neck  and  lower  jaw, 
and  ia  apt  to  attribute  it  to  a  cold.  As  the  symptoms  become  more 
noticable,  there  is  difficulty  in  mastication  and  deglutition,  and  these 
acts  are  attended  witli  more  or  less  pain.  The  lower  jaw  becomes 
fixed,  as  the  depressors  are  unable  to  overcome  the  spastic  contrac- 
tion of  the  temporal  and  masseter  muscles.  The  face  becomes  dis- 
torted, the  muscles  of  expression  contracting,  and  producing  the 
characteristic  risus  sardonicus.  The  spasmodic  condition  gradually 
involves  the  other  groups  of  muscles,  the  wrists  and  fingers  being 
the  only  parts  of  the  body  not  sharing  in  the  general  and  gradually 
increasing  contraction.  The  trunk  becomes  rigid,  and,  on  movement 
of  the  diaphragm,  a  severe  pain  passes  from  the  ensiform  cartilage 
through  the  body,  accompanied  by  a  distressing  dyspnoea.  The 
lower  extremities  are  in  most  cases  in  a  line  with  the  body,  the  head 
is  drawn  back  and  fixed,  and  the  arms  either  parallel  with  the  truuk 
or  drawn  across  the  chest.  The  abdomen  is  is  hard  and  broad.  In 
general,  the  powerful  muscles  of  the  back  and  limbs  bind  the  body 
i;i  the  form  of  a  bow,  and,  during  exacerbation,  the  patient  rests  upon 
the  occiput  and  heels.  This  position  is  termed  "opisthotonos." 
More  rarely  the  spiue  is  bent  forward  and  the  head  comes  in  con- 
t.-ict  with  the  knees,  a  condition  of  "emprosthotouos."  Still  more 
uncommon  is  "pleurosthotonos,"  the  muscles  of  one  side  of  the  body 
giving  a  lateral  curvature  to  the  spinal  column.  The  muscular 
spasm  is  continuous,  but  there  are  paroxysmal  exaggerations,  so 
severe  as  to,  in  some  cases,  project  the  patient  from  bed.  These 
convulsive  seizures  have  been  known  to  fracture  a  bone  or  rupture 
a  muscle.  They  are  excited  by  attempt  at  muscular  action,  or  are 
spontaneous.  Soon,  however,  sudden  noises  or  any  disturbance  will 
produce  them,  and  the  patient  lies  in  constant  fear  of  another  seizure. 


266  SPECIFIC  INFECTIOUS  DISEASES. 

During  the  interval  when  the  cramping  pain  ceases,  there  is  sore- 
ness and  aching  in  the  muscles.  The  bowels  are  almost  always 
constipated.  Frequently,  contraction  of  the  sphincter  muscle  of  the 
bladder  causes  retention  of  urine.  Here  priapism  will  often  be 
noticed.  The  body  is  wet  with  a  profuse  perspiration.  The  mind 
remains  unclouded,  and  the  patient  retains  his  faculties  to  the  List. 
As  the  result  of  the  excessive  muscular  contraction,  the  pulse  and 
temperature  are  more  or  less  affected.  Frequently,  just  before 
death,  the  temperature  rises  as  high  as  114°  F.  As  food  cannot  be 
taken,  and  rest  is  impossible,  exhaustion  begins  early,  the  patient 
lasting  only  two  or  three  days.  Respiration  is  greatly  embarrassed 
during  the  spasms,  and  death  often  occurs  from  apncea. 

CHRONIC  TETANUS:  TETANUS  MITIS. — In  chronic  tetanus  there  is 
a  much  longer  period  of  incubation.  Barely,  an  acute  attack  may 
assume  a  chronic  type,  and,  if  so,  there  is  a  possibility  of  recovery. 
In  tetanus  mitis,  the  muscular  involvement  is  extensive,  but  there 
are  intervals  when  there  is  a  partial  cessation  of  the  spasm.  In 
favorable  cases,  these,  growing  longer,  permit  of  the  patient's  obtain- 
ing some  rest.  Some  few  of  these  cases  recover.  A  mild  form  of 
tetanus,  where  the  muscles  of  the  neck  and  face  are  alone  involved, 
is  termed  "trismus." 

Diagnosis. — From  cerebral  or  cerebro-spinal  inflammation,  by 
there  being  no  coma  or  delirium,  and  the  absence  of  fever  during  the 
intervals  of  the  attacks. 

In  strychnia  poisoning,  consciousness  is  lost,  the  muscles  of  the 
neck,  head,  and  jaw  are  not  primarily  affected,  there  is  retinal  hyper- 
sesthesia,  and  objects  look  green.  The  vomitus,  when  analyzed,  will 
give  the  strychnia  reaction.  Hjrsteria  or  epilepsy  may  slightly 
resemble  tetanus,  but  only  during  its  earlier  stages.  In  its  milder 
forms,  it  has  been  mistaken  for  rheumatic  inflammation  of  the  jaws. 

Prognosis. — The  prognosis  is  grave,  especially  in  wounds 
received  in  battle.  Chronic  cases  occasionally  recover.  After  the 
fifth  day,  there  is  a  fighting  chance,  and  when  the  patient  passes  the 
twelfth  day,  the  prognosis  is  quite  hopeful.  The  disease  is  invaria- 
bly fatal  in  the  very  young,  where  the  period  of  incubation  is  short, 
and  when  rigidity  begins  early. 

Treatment. — PROPHYLAXIS. — All  suspicious  injuries  should  be 
disinfected.  Where  the  wound  has  become  foul,  or  when  it  has  been 
produced  by  some  dirty  object,  especial  care  should  be  taken  to  ren- 
der it  aseptic.  Foreign  bodies  should  be  sought  for  if  there  is  a 
possibility  of  their  having  found  lodgment  in  the  tissues.  In  epi- 
demics, all  cases  should  be  isolated. 

MANAGEMENT. — As  in  rabies,  the  patient  should  be  placed  in  a 


TETANUS.  267 

darkened  room,  and  kept  absolutely  quiet.  All  noises,  and  everything 
of  a  disquieting  nature,  should  be  prevented.  Chloroform  is  admin- 
istered by  inhalation,  frequently.  Chloral  by  rectum,  and  morphine 
subcutaneously,  are  administered  in  large  doses,  milder  acting  drugs 
being  useless.  Potassium  bromide,  ji  every  three  hours,  is  highly  rec- 
ommended. It  may  be  combined  with  the  chloral.  The  rigidity  of 
the  muscles  may  be  partially  overcome  by  deep  hypodermic  injec- 
tions of  atropine.  Amyl  nitrite  and  ghnoin,  theoretically,  should  help 
to  relieve  the  spasm,  and  have  been  used  more  or  less  successfully,  in 
tetanus.  As  we  desire  to  disturb  the  patient  as  little  as  possible, 
remedies  that  may  be  administered  by  inhalation,  subcutaneously,  or 
by  rectum,  are  of  prime  importance.  Curare,  being  a  motor  paral- 
yzer,  is  indicated,  and  may  be  pushed  to  its  full  physiological  influ- 
ence. Of  the  crude  drug,  we  may  administer  from  gr.  l-20th  to  l-5th. 
Curarine  may  be  used  hypodermically,  in  doses  of  from  l-200th  to 
1-lOOth  of  a  grain. 

A  valuable  remedy,  and  one  which  may  be  obtained  almost  any- 
where, is  tobacco.  The  officinal  infusion  (31— Oi)  may  be  given  by 
enema,  fiv  being  the  maximum  dose.  In  administering,  we  regulate 
the  dose  and  time  of  repetition  by  the  effects  produced.  It  should 
be  used  cautiously.  It  is  absorbed  very  rapidly  by  the  stomach, 
the  alkaloid  being  given  in  minute  doses.  If  desirable  to  adminis- 
ter hypodermically,  the  following  formula  may  be  used:  B  Nico- 
tine gr.  ss.,  aqua  dest.  jii.  M.  Sig.  l-24th  gr. 

Hale  asserts  that  passiflora  incarnata  is  a  cure.  It  is  probably 
not  superior  to  gelseinium  and  scutellaria,  which,  while  of  benefit 
in  trismus,  fails  in  tetanus.  Where  there  is  retention  of  urine,  the 
catheter  should  be  used.  Highly  nutritious  foods  should  be  given, 
either  through  a  stomach  tube  or  by  enemata.  Success  has  been 
reported  with  injections  of  the  tetanus  anti-toxin  of  Tizzoni  and 
Cattaui. 

But  we  cannot  expect  to  cure  tetanus  with  specifics  in  many 
instances.  When  the  period  of  incubation  is  long-continued,  as  fre- 
quently occurs,  we  will  find  that  the  general  system  has  taken  on  a 
septic  condition,  which  must  be  corrected  before  anti-spasmodics  will 
afford  much  satisfaction.  Each  individual  case  will  require  careful 
analysis,  and  where  the  best  anti-spasmodic  may  fail,  the  properly 
directed  antiseptic  treatment  may  promise  much.  I  have  in  recollec- 
tion a  severe  case  of  trismus,  which  occurred  years  ago,  that  seemed 
to  be  rapidly  passing  into  a  hopeless  stage,  in  the  hands  of  an  allo- 
pathic physician,  which  rapidly  improved,  and  nearly  recovered 
within  a  week,  when  alcoholic  vapor  baths  were  administered  every 
twenty-four  hours,  and  their  action  aided  by  the  internal  administra- 


268 


SPECIFIC  INFECTIOUS  DISEASES. 


tion  of  sulphite  of  sodium  and  baptisia,  the  former  drug  being  promi- 
nently indicated  by  the  pasty-white  coating  ou  the  tongue. 

In  malarial  regions,  periodicity  may  be  a  marked  feature  of  the 
disease,  the  spasms  becoming  violent  during  the  exacerbations,  and 
almost,  or  quite,  disappearing  during  the  remissions.  Here  we  must 
exhibit  quinine,  in  antiperiodic  doses,  promptly,  if  we  are  to  expect 
benefit  from  other  treatment 

The  physlo-medicalists  expect  the  steam  bath  to  accomplish  much 
toward  a  cure,  and  this,  aided  by  such  relaxauts  as  lobelia,  scutettaria, 
gelsemium,  etc.,  constitutes  a  very  effective  means  of  treatment,  these 
practitioners  being  very  successful  here. 

Aplopafypus  laricifolius,  if  the  fresh  plant  can  be  obtained,  is  an 
excellent  remedy,  though  whether  much  can  be  done  with  a  tincture 
without  a  fomentation  of  the  plant  to  the  affected  part,  remains  to  be 
proven  by  experience.  From  experience  with  it  in  veterinary  prac- 
tice, upon  my  own  carriage  horse,  I  am  not  favorably  impressed 
with  it. 

XXIV.  ACUTE  GENERAL  TUBERCULOSIS. 

Synonyms. — Acute  Miliary  Tuberculosis;  Typhoid  Tubercu- 
losis. 

Definition. — An  acute,  infectious  disease,  most  common  to  the 
period  of  puberty,  characterized  by  the  rapid  dissemination  of  tuber- 
cles throughout  the  entire  body  by  auto-infection,  the  tubercles 
being  iisually  concentrated  in  some  vulnerable  portion,  such  as  the 
lungs,  the  mesenteric  glands,  or  the  meninges,  with  almost  invariably 
rapid  and  fatal  termination. 

Etiology. — An  understanding  of  the  etiology  of  this  disease 
necessitates  a  study  of  that  of  tuberculosis  in  general,  as  acute  gen- 
eral tuberculosis  is  but  a  variety  of  a  disease  which  manifests  itself 
in  various  phases.  For  many  years  the  study  of  tubercle  has  been 
attended  by  much  obscurity  and  dissatisfaction.  The  doctrine  was 
long  adhered  to  that  tubercular  deposit  was  a  result  of  inflammatory 
action,  it  being  due  to  some  peculiar  predisposition  of  the  system — 
to  a  dyscrasia.  This  idea  has,  in  recent  years,  been  well  proven  a 
fallacy,  and  the  individuality  of  the  disease — its  tangible  identity — 
pointed  out.  Tubercle  is  now  believed,  by  modern  pathologists,  to 
arise  from  the  destructive  action  of  the  tubercle  bacillus,  a  parasitic 
microorganism,  the  discovery  of  which  was  announced  by  Koch,  in 
1882. 

The  tubercle  bacittus  is  a  slender  rod,  which  is  about  one-third  the 
diameter  of  a  red  blood-corpuscle  in  length,  and  about  five  times  as 
long  as  broad.  It  may  be  straight  or  slightly  curved,  as  seen  under 


ACUTE  GENERAL  TUBERCULOSIS. 


269 


the  microscope,  uniform  in  appearance  throughout,  except  that  cer- 
tain individuals  exhibit  from 
four  to  six  highly  refractive 
spherical  spaces  along  the  body, 
regular  intervals,  which  are 
supposed  to  represent  spores. 
These  seem  to  be  particularly 
numerous  when  tubercular  dis- 
ease is  developing  rapidly, 
while  in  cases  which  are  quies- 
cent, or  retrograding,  the  spores 
are  absent.  The  bacilli  mani- 
fest a  remarkable  resistance  to 
destructive  agencies,  and  retain 

r*f  —-••"•*•««*•  «•*  **•»          their  vitality  almost  indefinitely, 

even  resisting  the  bleaching 
action  of  acids,  when  once  stained  in  the  bacteriological  laboratory. 
Bacilli  may  supposedly  be  expectorated  in  tuberculous  material, 
and  become  a  part  of  the  common  dust,  by  desiccation  and  exposure, 
to  afterward  enter  the  lungs  of  uncontaminated  individuals  through 
inspiration,  during  a  disturbance  in  the  atmosphere,  and  produce 
fatal  infection,  provided  the  subjects  are  susceptible. 

It  is  not  difficult  to  explain  many  of  the  seeming  inconsistencies 
of  the  theory  of  the  bacillus-origin  of  tuberculosis.  It  has  long  been 
a  recognized  theory  that  the  disease,  or  predisposition  to  it,  is  hered- 
itary. This  doctrine  need  not  be  greatly  disturbed  by  the  new 
pathology.  Some  individuals  seem  remarkably  susceptible  to  the 
disease,  while  others  seem  proof  against  it,  and  this  receptivity  tends 
to  run  in  families,  though  not  so  confined,  by  any  means.  A  con- 
sumptive wife  may  infect  her  husband,  while  perishing  from  the  dis- 
ease, and  vice  versa,  the  activity  of  the  disease-agency  remaining 
dormant  in  the  second  individual  for  years,  to  afterward  develop  an 
activity  fatal  to  that  individual,  and,  possibly,  to  others  intimately 
associated.  People  thrown  much  together  are  liable  to  communicate 
it  to  one  another.  Houses  in  which  consumptive  families  have 
resided,  seem  to  retain  the  infection  for  years,  and  those  of  the  most 
perfect  physique  may  develop  the  disease  from  occupying  them 
afterward,  thoiigh  they  may  remain  the  hosts  of  the  bacilli  for  years 
before  active  disease  becomes  manifest.  Public  institutions,  especi- 
ally penitentiaries,  where  close  confinement  is  the  rule,  seem  to  breed 
the  infection.  It  is  a  notorious  fact  that  tuberculosis  is  very  com- 
mon in  these  institutions,  and  that  the  most  robust  and  hardy  con- 


270  SPECIFIC  INFECTIOUS  DISEASES. 

atitutions  succumb  to  it  after  a  few  years*  confinement,  where  it  has 
been  breeding  for  a  long  time.  The  disease  has  even  been  conveyed 
from  a  consumptive  mother,  through  the  placenta,  to  the  child  in 
utero. 

Diet  is  not  an  uncommon  source  of  contamination.  The  tuber- 
cle bacillus  thrives  in  other  animals  than  man,  especially  in  boviiies. 
Cow's  milk  may  therefore  be  contaminated  from  within,  and  may 
become  a  prolific  source  of  the  disease.  The  custom  which  has  pre- 
vailed within  the  past  years  so  largely  of  raising  children  on  con- 
densed milk,  has  doubtless  much  to  do  with  the  presence  of  miliary 
tuberculosis  at  the  period  of  adolescence,  the  activities  which  ure 
then  aroused  in  the  orgauism  assisting  in  the  rapid  distribution  of 
the  bacilli  and  their  speedy  destructive  action.  Doubtless  there  are 
some  who  resist  the  infection  when  exposed,  and  escape  altogether, 
while  others  may  become  hosts  of  the  parasites  and  resist  them  suf- 
ficiently to  reach  adult  life,  before  some  predisposing  accident  places 
the  coustitution  in  a  sufficiently  depraved  condition  for  the  bacilli  to 
accomplish  their  ravagea 

Pathology. — In  acute  miliary  tuberculosis,  the  bacilli  may  be 
distributed  from  any  center  where  they  first  become  lodged,  through 
the  lymphatics,  veins,  and  even  the  arteries,  becoming  disseminated 
through  all  the  tissues  of  the  body,  except,  perhaps,  those  of  the 
salivary  glands  and  pancreas  (though  it  is  now  asserted  that  the 
last-named  organ  is  not  exempt). 

The  lungs  are  most  frequently  and  largely  involved,  then  the 
liver,  intestines,  kidneys,  spleen,  pia  mater,  peritoneum,  pleura,  dura 
mater,  and  brain.  Deposits  are  more  rarely  and  sparsely  distributed 
in  the  thyroid  gland,  suprarenal  bodies,  female  genitals,  striped  mus- 
cles, and  stomach. 

When  the  lungs  are  infiltrated,  the  condition  is  easily  recognized 
by  the  eye  upon  autopsy.  The  organs  are  filled  with  little  gray 
transparent  nodules  of  varying  size,  some  being  so  small  as  to  be 
hardly  noticeable,  while  others  are  of  the  size  of  a  pin's  head,  or  a 
millet  seed.  If  a  portion  of  the  lung  be  taken  between  the  finger 
and  thumb,  it  imparts  a  hardened,  shotty  sensation,  and,  if  the  lung 
be  sliced,  lumpy  elevations,  corresponding  with  these  bodies,  may  be 
observed  upon  the  freshened  surface.  They  are  usually  transparent, 
though  some  of  them  may  have  an  opaque  center,  suggesting  the 
commencement  of  gaseous  changes.  Inflammatory  changes  are  also 
more  or  less  marked  in  the  lung  tissues,  such  as  oedema,  catarrh  of 
the  mucous  membrane,  plastic  exudation,  etc.  The  pleura  may  be 
involved,  and  found  to  be  the  seat  of  more  or  less  tubercular  deposit, 
as  well  as  of  former  inflammatory  action.  Sometimes  the  tuberculi- 


ACUTE  GENERAL  TUBERCULOSIS.  271 

t 

zation  is  confined  to  a  portion  (as  a  single  lobe)  of  the  lung.  The 
liver  and  spleen  present  similar  appearances  when  notably  affected, 
the  tubercles  being  quite  evenly  distributed  through  the  organs,  and 
showing  a  slight  tendency  to  coalesce. 

Tubercles  show  a  strong  tendency  to  caseation,  in  most  instances, 
but  this  disease  runs  its  course  so  rapidly  that  little  change  in  this 
direction  occurs.  In  all  fresh  tubercles,  bacilli  are  found  upon 
microscopic  examination,  but  the  sputum  does  not  contain  these 
microorganisms  in  this  affection,  as  they  do  not  break  down  before 
death.  When  the  tubercle  has  gone  on  to  necrosis  and  caseation, 
they  are  not  so  abundant,  only  the  spores  remaining  in  the  cheesy 
detritus. 

Symptoms. — A  prominent  symptom  is  fever,  usually  ushered 
in  with  a  chill,  or  a  succession  of  chills.  The  fever  is  irregular,  the 
temperature  running  from  102°  to  104°,  the  skin  being  hot  and  pun- 
gent, sometimes  dry,  and  sometimes  bathed  in  a  sticky  perspiration, 
the  pulse  being  remarkably  feeble  and  rapid,  the  tongue  pointed,  and 
reddened  at  the  tip  and  edges,  or  dry,  brown,  and  fissured,  the  urine 
scanty  and  high  colored  and  the  bowels  constipated,  unless  there  is 
intestinal  irritation. 

Soon  there  is  a  hectic  flush  on  the  cheek,  the  skin  becomes  trans- 
parent, with  prominent,  superficial  veins;  rapid  emaciation  follows, 
with  extreme  prostration.  Cutaneous  eruptions,  such  as  sudamina, 
roseolous  rash  on  the  chest  and  abdomen,  and  herpes  labialis,  are 
not  infrequent  accompaniments. 

A  remarkable  feature  of  most  cases  is  the  pulmonary  irritation, 
manifested  by  dry,  hacking  cough,  with  succeeding  expectoration, 
muco-purulent,  at  first,  and,  later,  sanguinous  in  character.  With 
these  symptoms  are  remarkable  increase  in  the  number  of  respira- 
tions (50  or  60  to  the  minute)  with  dyspnoea,  and  cyanotic  expres- 
sion of  countenance.  Sibilant  and  subcrepitant  rales  now  abound, 
and  areas  of  dullness,  with  bronchial  breathing,  are  found  later  on. 

When  the  meninges  are  principally  affected,  there  is  intense 
headache,  photophobia,  extreme  restlessness,  delirium,  facial  palsies, 
stupor,  convulsions,  coma,  and  Cheyene-Stokes  breathing.  Tuber- 
cles may  occur  upon  the  retina,  with  attending  visual  defects. 

When  the  intestine  and  peritoneum  are  the  principal  points  of 
deposit  of  the  tubercles,  there  are  pain,  tenderness,  abdominal  full- 
ness, diarrhoea,  and,  often,  gastric  irritability. 

The  disease  may  last  five  or  six  weeks,  though  it  usually  termi- 
nates fatally  in  from  two  to  four.  Death  most  frequently  results 
from  pulmonary  oedema  and  asphyxia,  or  cerebral  amemia  and  col- 
lapse, though  when  the  meninges  are  largely  involved,  convulsions, 
paralysis,  or  coma,  may  terminate  the  scene. 


272  SPECIFIC  INFECTIOUS  DISEASES. 

Diagnosis. — The  irregular  fever,  the  marked  local  symptoms, 
usually  of  pulmouary  origin,  the  absence  of  epistaxis  (a  common 
symptom  in  the  early  part  of  typhoid  fever)  and  markedly  rapid  res- 
piration, with  cyanotic  symptoms,  will  distinguish  this  disease  from 
typhoid  fever,  which  it  resembles  somewhat,  in  its  superficial  aspects. 
It  also  resembles  cerebro-spinal  fever  when  the  tubercles  involve 
the  meninges  and  brain,  in  some  respects,  though  it  runs  a  more  rapid 
course  than  the  slow  form  of  that  disease,  and  is  not  attended  by 
the  tonic  spasms  which  mark  the  active  form. 

Prognosis. — The  prognosis  is  almost  invariably  fatal.  All  that 
can  be  expected  of  treatment  is  to  palliate  the  most  unpleasant 
symptoms,  and  render  the  last  hours  of  the  patient  as  endurable  as 
possible. 

Treatment. — This  must  be  unsatisfactory,  at  best  There  must 
necessarily  be  a  steady  progress  from  bad  to  worse,  and  the  treat- 
ment which  may  succeed  in  palliating  to-day,  will  naturally  lose  its 
effect  to-morrow,  seeing  that  the  disease  is  steadily  progressing 
toward  a  fatal  termination,  and  that  the  structural  changes  are  con- 
tinually more  and  more  aggravated.  However,  we  may  lessen  the 
severity  of  some  of  the  unpleasant  symptoms,  and  do  this  in  the 
beginning  without  the  use  of  opiates  to  any  great  extent,  though 
toward  the  close  of  the  disease  opiates  are  about  all  that  will  afford 
any  relief  from  the  cough  and  other  unpleasant  symptoms. 

Gastric  irritation  will  be  a  common  cause  of  complaint,  nausea 
and  disgust  for  food,  being  a  common  feature.  To  relieve  this,  as 
well  as  to  control  the  fever  and  restlessness,  a  combination  of  aco- 
nite and  rhus  tox.  will  be  found  excellent.  Add  five  drops  of  aconite 
( Lloyd's  or  Worden's )  and  ten  or  fifteen  drops  of  a  saturated  tinc- 
ture of  fresh  rhus  tox.  leaves  to  half  a  glass  of  water,  and  give  a  tea- 
spoonful  every  hour.  This  excellent  prescription  will  render  good 
service  for  a  long  time,  and  even  throughout  the  disease,  lessening 
the  fever,  quietiug  nervous  erythism,  and  alleviating  pulmonary  irri- 
tation, to  considerable  extent 

The  lungs  will  usually  demand  something  positively  soothing,  to 
lessen  the  tendency  to  continual  hacking  cough.  It  is  best  to  avoid 
morphine  internally  here  as  long  as  possible,  and  the  following  pre- 
scription, used  in  the  form  of  a  spray,  by  inhalation,  will  serve  a  good 
purpose,  for  a  time,  at  least.  &  Essence  of  peppermint  ji,  aqua  ?i, 
morphia  sul.  gr.  i,  glycerine  31,  carbolic  acid  gtt.  xv.  Mix,  and  use 
as  often  as  required,  three  or  four  inhalations  of  the  vapor  being 
taken  at  a  time. 

Sometimes  antifebrin  will  be  excellent,  to  lessen  the  fever  and 
soothe  the  pulmonary  irritation,  and  there  can  be  no  objection  to  its 


ACUTE  GENERAL  TUBERCULOSIS.  273 

use  here,  as  there  can  be  no  danger  of  after-effects,  seeing  that  the 
case  is  hopeless  at  any  rate.  When  these  measures  fail,  the  internal 
administration  of  morphine  may  be  begun,  to  quiet  unpleasant  symp- 
toms. Codeine  is  often  preferable  to  morphine  in  alleviating  cough 
and  other  unpleasant  features,  as  it  interferes  less  with  the  secre- 
tions, and  is  less  irritating  to  the  nervous  system.  It  may  be  admin- 
istered in  syrup,  in  doses  of  from  l-4th  grain  to  2  grains. 

To  assist  in  alleviating  the  pungent  heat  of  the  surface  and  pro- 
moting rest,  as  well  as  to  restrain  the  colliquative  sweats  which  are 
liable  to  be  present,  a  cool  solution  of  citric  acid,  ji  to  the  pint  of 
water,  may  be  used  to  sponge  the  surface,  once  or  twice  a  day. 

Stimulants,  such  as  quinine,  or  whisky,  should  be  avoided,  as 
they  can  but  increase  the  discomfort  of  the  patient.  Only  sufficient 
food  to  supply  the  demands  of  hunger  should  be  given,  and  plenty 
of  cold  water  (as  this  will  usually  be  craved)  may  be  allowed,  though 
iced  water,  when  taken  too  freely,  is  liable  to  provoke  abdominal 
pain. 

During  the  last  few  days,  it  may  be  necessary  to  administer  opi- 
ates freely,  to  control  the  cough  and  lessen  the  restlessness.  Abdom- 
inal pain  may  demand  colocynth,  dioscorea,  or  nux,  and  diarrhoea  may 
call  for  bismuth  and  morphine,  in  appropriate  doses. 

XXV.   SYPHILIS. 

Synonyms. — Pox;  Lues  Venerea. 

Definition. — A  specific,  contagious  disease,  of  venereal  origin, 
of  slow  development  and  chronic  course,  which  may  be  congenital 
or  acquired,  manifesting  itself,  when  inoculated,  by  a  series  of  path- 
ological changes,  which  usually  occur  in  regular  order,  as  follows : 
First,  a  special  tissue-change  at  the  point  of  introduction,  occurring 
from  twenty-one  to  twenty-five  days  after  inoculation  (primary  syph- 
ilis) ;  second,  constitutional  symptoms,  which  develop  within  two  or 
three  months  afterward,  characterized  by  fever,  cutaneous  eruptions, 
irritation  and  ulceration  of  the  mucous  membranes,  especially  that 
of  the  pharynx  (secondary  syphilis);  and  third,  granulomatous 
growths,  which  develop  three,  four,  or  five  years  afterward,  affecting 
the  muscles,  bones,  and  skin  (tertiary  syphilis). 

Historical  Note. — Though  doubtless  a  disease  of  greater  antiq- 
mty,  general  attention  was  not  called  to  syphilis  as  a  peculiar  and 
formidable  disease,  until  the  year  1494,  when  it  occurred  as  an  epi- 
demic, among  the  troops  of  the  French  king,  Charles  VIII,  who  was 
then  besieging  Naples.  From  here,  it  seemed  to  spread  all  over 
Europe,  and  contemporary  medical  writers  of  various  nations  styled 


274  SPECIFIC  INFECTIOUS  DISEASES. 

it,  according  to  caprice  and  prejudice,  the  "French  disease;"  the 
"Neapolitan  disease;"  the  "Spanish  disease;"  the  "German  disease," 
etc.  As  this  outbreak  was  contemporary  with  the  return  of  Colum- 
bus' sailors  from  the  voyage  of  American  discovery,  a  popular  belief 
arose  that  the  malady  had  been  transmited  from  the  American 
Indians.  It  soon  became  apparent  that  the  disease  originated  from 
sexual  intercourse,  and  that  crowded  quarters,  promiscuous  and 
excessive  indulgence,  and  indifference  to  slight  venereal  abrasions, 
promoted  the  spread  of  the  affection  in  virulent  form ;  and  it  is  not 
unlikely  that  these  circumstances  favored  its  rapid  spread  and 
alarming  prevalence,  in  Charles'  army. 

For  nearly  three  centuries  afterward,  the  profession  universally 
confounded  all  forms  of  venereal  disease  with  syphilis,  and  consid- 
ered them  of  common  origin.  In  1767,  Balfour  declared  that  gon- 
orrhoea was  a  separate  disease,  distinct  from  other  forms  of  venereal 
disorder,  and  a  local  affection.  These  views  were  combated  by  the 
profession  generally,  however,  and  it  was  nearly  thirty  years  later 
(1793)  before  another  writer  of  distinction  (Benjamin  Bell)  espoused 
this  doctrine.  Still  the  profession  stood  aloof  from  such  views,  and 
it  finally  remained  for  Eicord,  thirty-eight  years  later  (1831),  to 
reiterate  them,  and  convert  the  profession  generally  to  their  accept- 
ance. Bicord,  however,  left  chancroid  and  syphilis  confounded,  and 
it  has  only  been  within  the  past  twenty  years  that  the  true  distinc- 
tions, which  enable  us  to  classify  the  latter  affection,  have  been  fully 
established. 

Etiology. — Doubtless  syphilis  is  due  to  the  presence  of  a  spe- 
cific germ,  which  causes  all  the  pathological  manifestations — where 
mercury  does  not  aggravate  its  action.  Several  observers,  notably 
Lustgarten,  have  observed  bacilli  in  the  secretions  and  morbid  prod- 
ucts of  syphilitics,  resembling  the  smegma  bacillus,  which  they 
believe  to  be  the  active  principle  of  the  disease.  Lustgarten  always 
found  them  inclosed  in  round  cells,  probably  the  micrococci  of  other 
observers.  Farther  study,  however,  seems  necessary  to  firmly 
establish  the  identity  of  the  microorganism  of  syphilis. 

While  contagious  through  inoculation  among  human  beings,  many 
assert  that  the  disease  is  not  communicable  to  the  lower  animals, 
others  claiming  that  apes  and  monkeys  are  susceptible.  One  attack 
affords  immunity  from  subsequent  ones  generally,  and  a  mother  who 
has  borne  a  syphilitic  infant  seems  protected  from  it,  even  though 
she  may  not  manifest  any  evidence  of  having  been  affected  as  a 
result,  the  suckling  and  handling  of  syphilitic  offspring  producing  no 
ill  effect,  while  other  wet  nurses  are  readily  contaminated. 

Acquired  syphilis  is  the  result  of  inoculation  with  the  blood  or 


SYPHILIS.  275 

morbid  discharges  of  a  person  who  has  been  comparatively  recently 
syphilized.  The  longer  the  disease  remains  in  the  system,  the  less 
liability  of  contamination  remains,  as  a  general  rule,  though  it  may 
be  communicated  many  years  after  the  primary  symptoms  have  dis- 
appeared, and  healthy  children  may  be  begotten  by  parents  recently 
syphilized.  In  from  three  to  five  years,  however,  the  liability  is 
almost  entirely  removed. 

While  inoculation  is  usually  the  result  of  impure  sexual  inter- 
course, there  are  many  other  avenues  through  which  accidental 
infection  may  take  place.  The  barber  may  transmit  it  with  hig 
combs,  brushes,  or  razors;  the  dentist,  with  his  lances  or  forceps; 
the  physician,  with  his  hypodermic  syringe  or  thermometer;  the  sur- 
geon, with  his  scalpel  or  other  instrument;  the  gynaecologist,  with 
his  speculums,  sounds,  forceps,  etc.,  and  parturient  women  may 
infect  the  fingers  and  hands  of  midwives.  Community  drinking 
cups  may  become  contaminated;  kissing  may  communicate  it;  bes- 
tial practices  often  result  in  the  communication  of  the  disease  to  the 
lips  and  tongue,  and,  probably,  insects  and  other  pests,  such  as  fleas, 
mosquitoes,  etc.,  may  convey  it  from  one  person  to  another. 
Humanized  vaccine  virus  is  quite  an  efficient  means  for  the  convey- 
ance of  syphilis,  and,  as  the  disease  has  thus  been  frequently  spread 
by  it,  little  use  is  made  of  humanized  virus,  though  it  is  much  more 
successful  in  transmitting  kine-pox  than  virus  from  the  bovine. 

Hereditary  transmission  may  be  referred  to  either  or  both  parents. 
Usually,  a  syphilitic  husband  or  wife  will  infect  the  other  parent 
before  conception  takes  place,  and  it  will  be  difficult  to  decide 
whether  the  child  is  syphilized  through  the  sperm,  or  through  the 
ovum.  However,  the  male  parent  may  impart  the  disease  to  the 
ovum  without  contaminating  the  mother,  and  the  child  be  born 
syphilitic,  while  the  only  apparent  influence  exerted  upon  the  mother 
may  be  that  of  rendering  her  immune  against  infection.  Or,  the 
mother  may  become  infected,  and  the  child  may  or  may  not  be  con- 
taminated through  the  placenta. 

General  Pathology. — The  primary  sore  (chancre)  of  syphilis 
is  surrounded  by  a  diffused  infiltration  of  the  connective  tissue  with 
small  round  epithelioid  and  giant  cells,  among  which  are  found  the 
bacilli  of  Lustgarten.  Thickening  of  the  intima  of  the  small  arter- 
ies, and  alterations  in  the  nerve-fibers  distributed  to  the  part,  also 
occur.  Hyperplasia  and  induration  of  the  neighboring  lymph-glands 
are  associated  with  this  condition.  When  the  chancre  is  mixed 
with  the  virus  of  chancroid,  rapid  breaking  down  of  these  tissues 
occurs,  the  edges  of  the  ulcer  thus  formed  becoming  raised  and 
indurated,  as  the  time  for  primary  development  arrives. 


276  SPECIFIC  INFECTIOUS  DISEASES. 

The  lesions  of  secondary  syphilis  are  many  and  diversified.  There 
are  ulceration  of  the  fauces  and  irritation  of  the  laryngeal  mucous 
membrane  (especially  when  mercury  has  been  administered  to  excess), 
eruptions  of  various  kinds  on  the  skin,  condylomata  about  the  gen- 
itals, iritis  and  other  eye  affections,  etc.,  these  being  attended,  dur- 
ing the  first  two  or  three  months,  by  protracted  fever. 

Tertiary  syphilis  is  marked  by  syphilomata  (gummata),  which 
develop  in  the  bones,  periosteum  (nodes),  skin,  muscles,  lungs, 
liver,  kidneys,  brain,  heart,  testes,  and  adrenals.  They  differ  in 
size,  varying  from  very  minute  bodies,  almost  microscopic,  to  large, 
solid  tumors,  an  inch  or  more  in  diameter,  these  being  hard  and 
resisting,  except  when  they  are  located  in  the  skin  or  mucous 
membranes;  when  breaking  down,  rapid  ulceration  may  attend. 
Histologically,  they  consist  of  granulomatous  tissue,  resembling 
tubercle,  a  cross-section  affording  a  grayish- white,  homogeneous 
appearance,  consisting  of  a  periphery  of  translucent,  fibrous  tissue, 
with  a  firm,  caseous  center.  Dense,  sclerotic  tissue  may  envelop 
clusters  of  three  or  more  of  these  bodies.  As  few  blood-vessels  are 
supplied  to  these  bodies,  there  is  a  constant  tendency  to  breaking 
down  of  the  central  portion,  by  coagulation  necrosis  and  the  forma- 
tion of  fibro-caseous  material,  while  progressive  fibrous  growth 
occurs  at  the  periphery.  Absorption  of  the  caseous  material  may 
ultimately  result,  a  fibrous  scar  remaining. 

ACQUIRED  SYPHILIS. 

Pathology  and  Symptoms. — The  .period  of  incubation  varies 
from  two  to  six  weeks,  though  it  usually  lasts  about  four.  Dur- 
ing this  time  there  are  no  symptoms,  unless  there  be  the  complica- 
tion of  gonorrhoea  or  soft  chancre,  these  diseases  then  taking  their 
accustomed  course,  until  the  syphilitic  infiltration  begins  at  the 
point  of  inoculation. 

INVASION. — The  primary  sore  of  acquired  syphilis  usually  begins 
as  a  small  pimple  (papule),  appearing  upon  an  indurated  base,  about 
the  fourth  week  after  inoculation.  This  may  slowly  increase  in  size, 
for  from  two  to  four  weeks,  and  then  mildly  ulcerate,  over  a  small 
surface  in  the  center.  Or,  the  papule  may  begin  to  ulcerate  at  once, 
and  assume  the  character  of  an  indolent  ulcer.  In  complicated 
cases,  the  primary  sore  is  painless  and  insignificant,  and  causes  lit- 
tle trouble,  unless  aggravated  by  heroic  treatment,  compressed 
beneath  the  prepuce,  or  irritated  by  chafing.  Unless  it  be  mixed 
with  the  virus  of  chancroid,  it  slowly  passes  through  a  protracted 
stage  of  mild  ulceration  for  several  weeks,  without  spreading,  and 
then  disappears,  leaving,  at  its  site,  an  indurated  and  reddened  spot. 


SYPHILIS.  277 

In  from  eight  to  fourteen  days  after  the  appearance  of  the  pri- 
mary sore,  painless  enlargement  of  the  lymphatic  glands  begins,  those 
traversed  by  lymphatics  arising  from  the  affected  spot  being  first 
involved,  the  enlargement  and  induration  gradually  extending  to  the 
entire  lymphatic  system.  The  enlargement  is  not  accompanied  by 
active  inflammatory  symptoms,  and  suppuration  never  occurs,  unless 
the  syphilitic  infection  is  complicated  with  secondary  pus  infection, 
an  accident  not  liable  to  attend  uncomplicated  syphilis.  When  the 
genital  organs  are  primarily  affected,  the  glandular  enlargement 
appears  first  in  the  inguinal  region,  in  a  week  or  two  more  the 
axillary  glands  become  involved,  and,  in  a  week  or  two  more,  the 
cervical  and  occipital.  These  are  now  perceptible  to  the  touch, 
enlarged,  and  hardened.  Should  the  inoculation  be  made  in  a  fin- 
ger or  hand,  the  lymphatic  enlargement  might  be  expected  to  appear 
first  in  the  axilla  of  the  corresponding  side,  in  such  instances  the 
glands  nearest  the  infected  spot  being  first  affected.  Sometimes  the 
lymphatics  themselves  are  enlarged,  feeling,  under  the  finger,  like 
hardened  cords. 

Secondary  symptoms  develop,  from  the  sixth  to  the  twelfth  week 
after  the  appearance  of  the  primary  sore.  These  vary  in  constancy 
of  order,  though  fever  is  often  an  early  symptom.  When  this  occurs, 
the  temperature  is  not  usually  high,  it  varying  from  101°  to  103°  F., 
though  it  occasionally  reaches  104°  or  105°.  This  is  attended  by 
headache,  loss  of  appetite,  muscular  pain,  insomnia,  emaciation,  and 
anaemia. 

Pharyngitis  is  quite  certain  to  come  on  early,  and  is  especially 
severe  if  the  patient  has  been  recently  mercurialized,  the  inflamma- 
tion then  extending  to  the  mouth,  and  becoming  ulcerative  in  char- 
acter, both  in  the  mouth  and  throat.  The  irritation  is  also  liable  to 
extend  to  the  larynx,  laryngeal  cough  and  aphonia  attending.  Some- 
times the  ulceration  is  deep  and  extensive,  rendering  deglutition 
painful,  and  giving  rise  to  much  other  local  unpleasantness.  Often 
the  stomatitis  involves  the  lips,  stubborn,  indurated  fissures  remain- 
ing here  for  months.  Aggravated  symptoms  of  this  character  are 
almost  always  due  to  the  action  of  mercury,  and  seldom  if  ever 
appear,  if  this  drug  is  avoided  from  the  start. 

About  the  eighth  week,  a  macular  eruption  appears  upon  the 
abdomen,  and  spreads  to  other  regions.  It  appears  on  the  chest 
during  the  ninth  week,  on  the  shoulders  the  tenth,  on  the  arms  dur- 
ing the  eleventh,  on  the  forearms  the  twelfth,  and  on  the  hands,  dur- 
ing the  thirteenth.  It  is  symmetrical,  appearing  on  both  halves  of 
the  body  simultaneously,  and  is  of  a  copper  color.  Papules  appear 
about  a  month  later.  A  row  of  these  may  be  situated  along  the 


SPECIFIC  INFECTIOUS  DISEASES 

margin  of  the  forehead,  constituting  the  Corona  Veneris.  Pustul>-* 
may  now  appear,  these  being  rarely  seen  however  before  the  fourth 
month.  They  may  be  small  and  hard,  feeling  "shotty"  under  pres- 
sure, like  the  eruption  of  small-pox,  or  large,  like  the  eruption  of 
impetigo.  They  may  ulcerate,  and  become  covered  by  rupial  crusts. 
Still  later,  a  squamous  eruption  may  appear,  resembling  psoriasis,  and 
often  termed  "syphilitic  psoriasis."  This  form  appears  most  com- 
monly on  the  palms  of  the  hands,  and  soles  of  the  feet. 

It  will  thus  be  observed  that  the  eruption  of  syphilis  is  poly- 
morphous, none  of  the  forms  being  distinctive  of  this  particular  dis- 
ease, though  the  polymorphous  character  is  peculiar  to  the  develo}  - 
ment  of  syphilis.  When  the  eruption  invades  mucous  membranes, 
mucous  patches,  warts,  and  condylomata  result. 

Syphilitic  eruptions  are  not  usually  painful,  or  sensitive.  They 
are  slow  of  development,  and  resisting  to  the  influence  of  treatment, 
months  being  occupied  in  producing  an  impression  on  them  with 
internal  remedies,  or  local  applications. 

ALopcscia  and  iritis  frequently  occur,  as  symptoms  of  the  second- 
ary stage,  especially  in  badly  treated  cases. 

Tertiary  syphilis,  it  is  believed  by  many,  is  the  result  of  mercuri- 
alization,  rather  than  of  the  disease  alone.  The  condition  could  not 
be  brought  about  by  mercury  alone,  and  it  is  doubtful  that  the  dis- 
ease would  reach  such  a  stage  without  the  pernicious  influence  of 
that  drug.  Eclectic  physicians,  of  long-continued  and  wide  experi- 
ence in  venereal  diseases,  aver  that  tertiary  syphilis  never  follows, 
where  mercurials  are  avoided  and  the  patient  has  been  properly 
treated  from  the  start,  with  vegetable  antisyphilitics. 

The  syphilides  of  this  stage  are  unsymmetrical,  and  tend  to  exca- 
vate the  tissues  deeply.  Bound,  deep  ulcers  occur  upon  the  skin 
and  mucous  membranes.  Sometimes  the  ulcerations  upon  the  skin 
are  tubercular  and  serpiginous,  and  these  are  always  stubborn  and 
chronic  in  character.  Periosteal  nodes  appear  along  the  shins,  ami 
these  are  accompanied  by  severe  nocturnal  (osteocopic)  pains.  Gum- 
mata,  which  undergo  various  degenerative  changes  at  a  later  period, 
may  develop  in  the  skin,  subcutaneous  structures,  or  internal  organs. 
When  gummata  develop  in  the  viscera,  they  are  liable  to  undergo 
fibrous  transformation,  with  subsequent  puckering  and  deformity, 
thus  giving  rise  to  serious  obstruction  of  the  function  of  the  part. 

The  brain  and  cord,  lungs,  liver,  digestive  tract,  circulatory  sys- 
tem, kidneys  and  testes  are  all  liable  to  the  deposition  of  syphilitic 
gummata. 

Gummata  in  the  brain  and  cord  form  tumors,  varying  in  size  from 
that  of  a  pea,  to  that  of  a  Avalnut.  They  seem  to  develop  from  the 


SYPHILIS.  279 

meuinges,  and  are  nearly  always  attached  to  the  dura  mater  or  pia 
mater.  They  may  occur  singly  or  in  masses,  and  are  most  frequently 
developed  in  the  cerebrum.  They  undergo  a  variety  of  changes, 
such  as  caseous,  fibrous,  or  cystic  degeneration.  They  do  not  occur 
as  frequently  in  the  cord  as  in  the  brain,  though  gummatous  tumors 
have  been  fouud  in  all  regions  of  this  structure. 

The  presence  of  gummata  in  the  brain  and  cord  gives  rise,  in  the 
early  period  of  their  presence,  to  meningitis,  arteritis,  and  localized 
foci  of  sclerosis.  Later,  as  the  arteries  become  occluded,  or  local  areas 
become  debilitated  by  the  meningeal  inflammation,  softening  of  the 
cerebral  structures  occurs.  Or,  cerebral  hemorrhage  may  occur 
as  a  result  of  syphilitic  arteritis,  the  weakened  vessels  giving  way. 

Tertiary  lesions  of  this  character  usually  coine  on  years  after  the 
first  appearance  of  the  disease,  though  occasionally  they  appear 
within  a  few  months.  Psychical  disturbances  develop  early  in  such 
cases,  and  the  careful  observer  soon  becomes  convinced  of  structural 
cerebral  disease.  Delirium,  either  abrupt  or  preceded  by  headache, 
giddiness,  etc.,  may  appear,  or  there  may  be  a  gradual  lapse  into  a 
condition  of  drowsiness  and  coma,  while  in  other  cases  paretic 
dementia  is  the  leading  symptom.  Convulsions  may  supervene,  epi- 
leptic seizures  sometimes  alternating.  Sometimes  cerebral  syphilis 
displays  the  symptoms  of  tumor  of  the  brain.  There  is  inflamma- 
tion of  the  optic  nerve,  with  headache,  vomiting,  convulsions,  etc. 
Sometimes  the  early  symptoms  may  be  abrupt,  resembling  results 
of  thrombosis  or  embolism,  hemiplegia  being  the  first  indication  of 
cerebral  disturbance.  In  other  cases,  there  may  be  loss  of  normal 
power  of  muscular  coordination,  the  gait  being  staggering  and 
unsteady,  like  that  of  a  drunken  person.  When  spinal  syphilis 
occurs,  the  gummata  are  attached  to  the  meninges,  and  imbedded  in 
the  substance  of  the  cord.  Meningeal  inflammation  may  be  provoked 
by  their  presence,  and  this  may  result  in  convulsions,  or  other  reflex 
action.  Sclerosis  may  develop  from  fibroid  changes,  locomotor 
ataxia  being  the  result,  or  the  various  symptoms  of  compression  of 
the  cord  may  arise,  from  the  presence  of  the  morbid  growth. 

Syphilis  of  the  lungs  is  common  in  the  new-born  subject  of  hered- 
itary syphilis,  and  in  acquired  syphilis  it  occasionally  occurs,  com- 
ing on  here  after  the  second  year.  Gummata,  varying  in  size  from 
that  of  a  pea  to  that  of  a  marble,  become  deposited  throughout  the 
hepatic  tissues.  When  these  are  numerous,  the  fibrous  changes 
which  occur  cause  such  marked  contraction  that  the  organ  becomes 
very  much  distorted  and  disfigured,  so  much  so  as  to  sometimes 
resemble  a  bunch  of  grapes.  However,  sometimes  the  gummata 
soften  and  liquefy  instead  of  undergoing  fibrous  chauge,  the  diseased 


280  SPECIFIC  INFECTIOUS  DISEASES. 

organ  becoming,  where  the  morbid  deposits  have  been  numerous, 
soft  and  fluctuating.  In  some  cases,  Glisson's  capsule  may  become 
thickened  through  the  syphilitic  influence,  perihepatitis  and  increase 
of  connective  tissue  giving  rise  to  contraction  ;md  deformity.  In 
many  cases,  the  symptoms  are  those  of  hepatic  cirrhosis.  There  are 
digestive  disturbances,  icteric  symptoms,  slightly  marked,  emaciation, 
and  ascites.  If  the  ascitic  fluid  be  evacuated,  and  careful  palpation 
be  made  over  the  right  hypochondriac  region,  the  marked  irritability 
of  the  organ  will  be  detected.  In  other  cases,  extensive  amyloid 
degeneration  of  the  liver  may  follow  the  deposition  of  the  gummata, 
this  involving  the  spleen  and  intestinal  mucosa  also,  and  there  will 
be  anaemia,  albuminuria,  and  anasarca,  or  ascites. 

In  syphilis  of  the  digestive  tract,  there  may  be  syphilitic  deposit  in 
the  oesophagus,  stomach,  small  intestine,  csBcum,  or  rectum.  When 
gummata  are  deposited  in  the  oesophagus,  stricture  is  the  result 
Syphilitic  ulceration  of  the  stomach  and  intestines,  as  well  as  of  the 
oesophagus,  is  rarely  met.  The  common  location  of  intestinal  syph- 
ilis is  the  rectum,  gummata  being  deposited  in  the  submucosa,  above 
the  internal  sphincter,  the  changes  which  follow  giving  rise  to  nar- 
rowing of  the  opening,  and  permanent  stricture.  These  changes  are 
gradual  in  their  enchroachment,  sometimes  occupying  years  for  the 
complete  development  of  the  rectal  stricture. 

Syphilis  of  the  circulatory  system  may  involve  the  heart  or  the 
arteries.  A  warty  endocarditis  occasionally  occurs  in  syphilitic  sub- 
jects, and  gummata  may  develop  upon  the  valves,  giving  rise  to 
various  secondary  changes,  such  as  fibrous  or  sclerotic.  The  myo- 
cardium may  be  the  seat  of  gummatous  growths  also,  these  caus- 
ing inflammatory  action,  and  even  rupture  of  the  heart-wall. 

The  arteries  may  be  occluded  through  a  syphilitic  arterio-sclerosis, 
or  so  weakened  that  aneurisms  result.  In  obliterating  eudarter- 
itis,  there  is  proliferation  of  the  subendothelial  tissue,  the  hyper- 
plasia  occurring  within  the  elastic  tunics,  and  enchreaching  upon  the 
lumen,  until  the  vessel  is  closed.  This  condition  is  not  peculiar  to 
syphilis,  however,  and  not  diagnostic  of  this  disease,  unless  there 
are  gummata  in  other  parts,  or  there  is  a  confirmatory  history  of 
syphilis.  When  nodular  gummata  develop  in  the  adventitia,  how- 
ever, there  can  be  no  mistake.  Globular  tumors  of  varying  size 
appear,  especially  upon  the  cerebral  arteries,  giving  rise  to  inflam- 
matory action  in  the  surrounding  tissues. 

The  kidneys  are  occasionally  the  seat  of  gummata,  though  these 
are  not  usually  numerous.  Cicatrices  are  found  upon  post-mortem 
examination,  though  there  are  no  clinical  symptoms  which  lead  to 
their  detection  during  life.  Possibly  in  future  time  the  further  per- 


SYPHILIS.  281 

fection  of  skiagraphy  will  enable  the  practitioner  to  determine  their 
existence  before  death. 

The  testicles  are  frequently  the  seat  of  gummatous  deposits,  the 
growths  occurring  in  indurated  masses,  in  the  substance  of  the  organ, 
and  not  in  the  epididymis,  as  in  tubercle.  The  gland  becomes 
enlarged,  but  the  swelling  is  painless,  and  does  not  tend  to  degener- 
ative change.  Syphilitic  orchitis  may  arise  independently  of  gummata, 
a  fibroid  degeneration,  with  increase  of  interstitial  elements  and 
gradual  contraction  of  the  organ,  ensuing.  This  is  a  slow  and  pain- 
less process,  involving  one  side  particularly,  it  being  recollected  that 
tertiary  lesions  are  not  symmetrical,  as  in  the  case  of  secondary 
lesions. 

CONGENITAL  SYPHILIS. 

Pathology  and  Symptoms. — Congenital  syphilis  presents  us 
with  all  the  pathological  conditions  found  in  acquired  syphilis,  except 
that  the  primary  lesions  do  not  develop.  If  the  disease  appear  while 
the  child  is  yet  in  utero,  it  may  be  still-born  (or  survive  a  few 
months),  with  all  the  symptoms  of  bad  cases  of  secondary  and  ter- 
tiary syphilis,  combined.  In  still-born  children,  and  even  in  those 
born  alive,  large  areas  of,  and  even  an  entire  lung,  may  be  affected 
with  loldte  pneumonia  of  the  fcettis,  a  condition  in  which  the  affected 
part  is  consolidated,  firm,  heavy,  and  airless,  presenting,  upon  section, 
a  grayish- white  appearance  (white  hepatization  of  Yirchow);  and 
miliary  gummata  are  scattered  through  the  structure.  The  alveolar 
walls  are  here  thickened  and  infiltrated,  and  the  cells  are  filled  with 
desquamated  and  swollen  epithelium. 

Diffused  syphilitic  infiltration  of  the  liver  is  often  present.  Though 
the  organ  preserves  its  form,  it  is  large,  hard,  and  unyielding  to 
pressure.  It  is  yellowish  in  appearance,  resembling  the  color  of 
sole-leather,  and  when  cut,  foci  of  infiltration  are  observable  upon 
microscopical  examination  (miliary  gummata)  and  connective  tissue 
is  found  greatly  increased  in  amount.  Jaundice  is  frequently  pres- 
ent, the  icterus  persisting  until  a  fatal  issue  follows. 

When  the  disease  exists  at  birth,  the  child  presents  a  wasted, 
wrinkled  appearance,  the  abdomen  is  abnormally  large,  and  there  are 
cutaneous  lesions,  especially  around  the  wrists  and  ankles  (bullae), 
and  upon  the  hands  and  feet  (pemphigus  neonatorum).  Snuffles  ;ire 
common  with  syphilitic  babies,  and  fissures  in  the  corners  of  the 
mouth  aud  herpetic  eruptions  behind  the  ears,  are  nearly  as  common. 
Ulceration  of  the  lips  is  often  present.  The  bones  are  liable  to  be 
diseased,  separation  of  the  epiphyses  usually  being  present  in  such 
cases. 

A  syphilitic  child  maybe  born  healthy,  and  thrive,  for  a  few  weeks 


282  SPECIFIC  INFECTIOUS  DISEASES. 

before  the  syphilitic  manifestations  appear.  Between  the  fourth 
and  eighth  weeks,  however,  irritation  in  the  nasal  passages  becomes 
manifest,  and  persists,  in  spite  of  ordinary  treatment  for  congestion 
of  the  Schneiderian  mucous  membrane.  There  are  snuffles  and 
mouth  breathing,  these  being  so  urgent  that  the  child  may  be  una- 
ble to  nurse.  This  syphilitic  rhinitis  becomes  progressive,  and  a 
catarrhal  discharge  is  soon  established,  varying  from  a  sero- 
pus  to  blood.  Ulceration,  followed  by  necrosis  of  the  nasal  bones, 
may  take  place,  unsightly  depressions  at  the  root  of  the  nose  often 
resulting.  Continuing  along  the  eustachian  tube,  the  middle  ear 
may  be  involved,  destruction  of  important  parts  here  terminating  in 
permanent  deafness.  Simultaneously  with  the  development  of  the 
suufflas,  or  soon  after,  cutaneous  eruptions  appear,  first  about  the  nates, 
in  the  form  of  irregular  brown  patches,  or  as  eczematous  or  erythem- 
atous  rashes.  Sometimes  papular  syphilides  appear  here  in  the 
beginning.  The  mouth  is  involved  early,  the  lips  and  tongue  pre- 
senting ulcers  and  fissures,  the  child  soon  communicating  the  dis- 
ease to  the  nipple  of  the  wet-nurse,  unless  artificially  nourished. 
The  disease,  in  the  form  of  infantile  syphilis,  is  very  infectious,  not 
only  the  wet-nurse  but  other  members  of  the  household  becom- 
ing contaminated,  possibly  through  kissing,  or  the  common  use  of 
towels  or  other  toilet  articles.  The  cuticular  appendages,  such  as 
the  hair  and  nails,  are  usually  affected,  the  hair  and  eyebrows  fall- 
out, and  onychia  developing.  Laryugeal  irritation  becomes  mani- 
fest in  many  cases,  the  voice  being  harsh  and  high  pitched,  the  cry 
of  the  syphilitic  child  being  thus  peculiar.  The  glands  are  not  gen- 
erally enlarged,  as  in  acquired  syphilis,  though  where  cutaneous 
lesions  are  severe  and  deep-seated,  neighboring  lymphatics  may 
become  affected.  The  liver  and  spleen  are  usually  enlarged,  and  hem- 
orrhages are  not  uncommon,  these  issuing  from  the  gums  and  umbili- 
cus, or  into  the  subcutaneous  tissue,  forming  hemorrhagic  patches 
beneath  the  skin. 

Syphilitic  children  usually  perish  before  the  period  of  infancy 
has  passed,  though  they  may  survive,  and  continife  to  live  through  a 
protracted  period  of  stunted  growth.  Childish  peculiarities  persist 
into  years  of  adolescence.  A  syphilitic  patient  at  twenty-one  may 
not  appear  more  than  ten  or  twelve  years  old.  If  the  child  seems  to 
have  recovered  during  infancy,  the  disease  is  likely  to  reappear  at 
puberty.  Then  he  may  present  a  wizened,  wasted  appearance,  and 
a  prematurely  old  look.  The  skin  is  sallow,  and  there  are  cranial 
peculiarities,  which  mark  the  presence  of  the  disease.  The  peculiar 
appearance  of  such  a  patient  is  designated  as  "infantilism."  The 
forehead  projects,  the  frontal  eminences  are  prominent,  and  the  era- 


SYPHILIS.  283 

nium  is  asymmetrical.  The  Hutchinson  teeth  are  present,  these 
being  characterized  by  a  notched  condition  of  the  cutting  edge  of 
the  middle  incisors,  which  are  peg-shaped — narrower  at  the  extrem- 
ities than  at  the  gums.  The  bridge  of  the  nose  is  sunken,  and  the  tip 
is  turned  up  (pug-nose).  About  the  period  of  puberty,  eye  aud  ear 
affections  are  liable  to  develop.  Of  eye  affections,  keratitis  and  iri- 
tis are  most  common.  The  keratitis  is  interstitial,  the  cornea  pre- 
senting a  steamy  appearance,  sometimes  one  and  sometimes  both 
being  affected.  After  a  time,  the  cloudiness  may  clear  up,  though 
spots  or  specks  of  opacity  may  remain  permanently.  While  a  vari- 
ety of  ear  affections  may  be  due  to  syphilis,  a  peculiar  kind  may 
develop  about  puberty,  in  which  deafness  comes  on  rapidly  and 
remains  permanently,  in  spite  of  treatment,  and  in  which  there  are 
no  obvious  local  lesions,  the  pathological  changes  probably  affecting 
the  labyrinth.  The  bones  tnay  be  involved,  both  early  and  late. 
Some  of  the  marked  cases  of  chronic  gummatous  periostitis  may  be 
mistaken  for  rickets. 

Synovitis,  enlargement  of  the  spleen,  and  gummatous  deposits  in 
the  liver,  kidneys,  and  brain,  may  all  occur  as  late  manifestations  of 
hereditary  syphilis,  as  well  as  of  the  early  stages. 

General  Diagnosis. — Syphilis  may  exist  in  obscure  form,  and 
be  the  underlying  factor  in  the  obstinacy  of  many  cases  which 
would  otherwise  improve  rapidly  under  medication.  A  proper  treat- 
ment, as  well  as  prognosis,  depends,  then,  upon  the  ability  of  the 
practitioner  to  recognize  and  provide  for  them.  There  is  a  disposi- 
tion on  the  part  of  many  patients  to  conceal  the  fact,  when  they  have 
been  affected  by  acquired  syphilis,  and  the  physician  must  be  pre- 
pared for  this,  and  draw  his  conclusions  accordingly.  As  few  are 
acquainted  with  all  the  symptoms  liable  to  follow,  however,  careful 
questioning  will  enable  the  physician  to  come  very  near  the  truth, 
however  well  the  patient  may  attempt  to  guard  it.  The  history  of 
throat  and  skin  lesions,  loss  of  hair,  emaciation,  etc.,  occurring  as 
associated  symptoms,  are  very  good  evidence,  when  attending  condi- 
tions already  suggest  the  disease.  In  primary  syphilis,  the  patient 
may  contract  gonorrhoea  coincidentally,  and  the  chancre  be  concealed 
within  the  urethra,  along  the  fossa  navicularis;  but  the  presence  of 
enlargement  and  induration  in  the  inguinal  region,  and  the  develop- 
ment of  mucous  and  cutaneous  lesions  later,  with  fever  and  loss  of 
strength,  will  convey  intelligence  of  the  specific  character  of  the  dis- 
ease. In  advanced  cases,  nodes  on  the  shins  or  other  parts  of  the 
skeleton,  old  scars,  and  more  or  less  thickening  of  the  lymphatic 
glands,  especially  in  the  inguinal  and  occipital  regions,  are  confirm- 
atory of  a  suspicion  of  the  presence  of  syphilis.  In  congenital  syph- 


284  SPECIFIC  INFECTIOUS  DISEASES. 

ills,  there  is  little  danger  of  mistaking  the  disease.  The  early 
appearance  of  snuffles,  in  conjunction  with  cutaneous  and  mucous 
lesions,  can  hardly  be  mistaken  for  any  other  affection.  The  pecu- 
liar developments  at  puberty,  already  described,  will  be  confirmatory 
testimony,  as  the  case  progresses. 

Prognosis. — In  these  days,  the  old  virulence  of  syphilis  seems 
to  have  become  nearly  exhausted.  With  rational  treatment,  few 
cases  of  acquired  syphilis  will  result  seriously,  or  even  develop  very 
unpleasant  secondary  symptoms,  while  tertiary  manifestations  may 
generally  be  entirely  avoided.  Unfortunately,  many  cases  of  this 
disease  fall  into  the  hands  of  old  school  physicians,  who  adhere  to 
the  stupidly  pernicious  practice  of  administering  mercury  during  the 
early  stages.  The  result  is,  that  the  following  lesions  are  more 
severe,  and  much  more  difficult  to  control.  We  can  promise  much 
more  to  a  patient  who  has  avoided  mercury  throughout,  than  one 
who  has  been  subjected  to  the  action  of  that  drug  for  several  weeks' 
time  in  the  start.  It  is  possible  that  mercury  may  suppress  the 
cutaneous  lesions  somewhat  at  first,  but  if  these  are  allowed  to 
come  out,  while  the  use  of  proper  vegetable  antisyphilitics  is  made, 
they  will  usually  disappear  permanently,  within  a  brief  period.  Mer- 
cury invariably  aggravates  the  mucous  lesions  about  the  mouth  and 
throat,  these  becoming  increased  and  prolonged,  as  mercurial  treat- 
ment is  persisted  in. 

Congenital  syphilis  is  less  amenble  to  treatment  than  the  acquired 
form,  though  it  is  possible  that  early  treatment,  through  the  mater- 
nal circulation,  might  avert  many  of  its  evils. 

Treatment. — Preventive  treatment  is  always  to  be  considered. 
A  syphilitic  patient  should  be  warned  to  avoid  the  common  use  of 
toilet  articles,  drinking  cups,  pipes,  etc.,  with  uncontaminated  per- 
sons. A  syphilitic  child  should  be  reared  on  the  bottle,  unless  its 
own  mother  nurse  it,  and  precautions  should  be  observed  as  to 
the  use  of  towels,  combs,  drinking-cups,  etc.,  and  other  children,  as 
well  as  adults,  should  avoid  kissing  and  fondling  it.  The  person  who 
attends  to  washing  its  clothing  should  see  that  there  are  no  abra- 
sions on  her  hands,  through  which  the  virus  may  find  entrance  to  the 
circulation.  With  an  intelligent  idea  of  the  nature  of  the  disease, 
suggestions  as  to  proper  care  to  guard  against  infection  will  natu- 
rally arise,  in  the  inind  of  every  thinking  person. 

The  medicinal  treatment  of  acquired  syphilis  is  simple,  and,  at  the 
same  time,  effective.  B.erberis  aquifolium  is  as  near  a  specific  for 
syphilis  as  we  can  hope  for,  in  any  case.  But,  as  syphilis  is  a  dis- 
ease of  slow  development  and  chronic  course,  we  must  not  expect  a 
few  weeks'  treatment  to  eradicate  it.  Many  patients  improve  so  rap 


SYPHILIS.  285 

idly  upon  it  that  they  finally,  in  a  few  weeks,  consider  themselves 
cured,  and  then  abandon  treatment,  to  their  ultimate  sorrow;  but 
when  continued  for  months  and  years,  nothing  could  be  more  satis- 
factory than  the  results  thus  obtained.  Syphilitics,  in  the  wasting 
stage  of  the  disease,  improve  in  appetite  and  flesh  under  this  rem- 
edy, debility  disappears,  and  former  vigor  is  soon  restored.  Peri- 
osteal  pains  subside  under  its  influence,  and  gummata  are  averted, 
though  it  possesses  no  power  to  discuss  them,  when  once  formed. 
But  the  ulceration  which  follows  their  breaking  up  in  the  skin  and 
mucous  membranes  becomes  less  stubborn,  and  usually  heals  within 
reasonable  time.  It  removes  the  cutaneous  eruptions  of  secondary 
syphilis  in  a  few  weeks,  and  assists  in  healing  the  patches  in  the 
mouth  aud  throat. 

Corydalis  formosa  is  a  remedy  which  rivals  berberis  aquifolium. 
To  avert  gummatous  periostitis  and  prevent  the  formation  of  nodes, 
it  is  probably  without  a  rival.  It  combines  well  with  berberis,  and 
I  am  in  the  habit  of  prescribing  as  follows,  in  most  cases  of  syphilis, 
for  constitutional  purposes :  B  Fluid  extract  berberis  aquifolium  fi, 
specific  corydalis  fss,  alcohol  fii,  aqua,  ad.  q.  s.,  Oi.  Sig.,  Take  a 
tablespoonful  four  times  daily.  This  combination  will  answer  every 
purpose,  where  syphilitic  cases  have  not  previously  been  subjected 
to  the  baneful  effects  of  mercury.  "When  this  drug  has  been  used, 
however,  tertiary  lesions  may  be  stubborn,  and  demand  the  employ- 
ment of  iodide  of  potassium,  to  hasten  the  liquefaction  of  syphilides, 
when  breaking  down  begins  in  the  skin  and  mucous  membranes. 
This  may  then  be  given  in  tolerably  large  doses  (gr.  x)  for  a  few 
weeks,  to  be  temporarily  discontinued,  until  the  patient  has  time  to 
recuperate  from  the  resulting  debility,  upon  berberis.  It  is  well,  in 
such  cases,  to  alternate  the  berberis  with  the  potassio  iodide,  as  well 
as  follow  with  its  temporary  administration. 

Stubborn  cutaneous  eruptions,  following  upon  the  administration 
of  mercurials,  may  sometimes  yield  to  large  doses  (gtt.  x)  of  Dono- 
van's solution,  repeated  three  or  four  times  a  day.  It  may  be  sug- 
gested that  this  combination  contains  mercury,  an  objection  which 
can  hardly  be  raised  to  its  use  when  the  system  has  already  been 
thoroughly  poisoned  with  the  drug.  Sometimes  stubborn  cutaneous 
lesions,  such  as  palmar  psoriasis,  can  be  cured  by  the  persistent  local 
use  of  Webster's  compound  sulphur  ointment :  Ify  Lanolin  Ib.  i,  ol.  tar 
f i,  sp.  m.  veratrum  ? i ;  thicken  with  powd.  sulphur.  This  should  be 
applied  morning  and  evening,  for  a  year,  constantly. 

The  primary  sore  of  syphilis  needs  little  attention,  unless  it  be 
developed  where  it  is  subjected  to  pressure  or  chafing.  Twenty 
drops  of  nitric  acid,  diluted  in  four  ounces  of  water,  constitute  a 


286  SPECIFIC  INFECTIOUS  DISEASES. 

cleansing  wash,  which  tends  to  heal  the  abrasion  and  prevent  the 
growth  of  condylomata.  It  should  be  applied  four  or  five  times 
daily.  When  the  chancre  is  concealed  beneath  a  constricted  prepuce 
(phymosis),  aggravation  is  liable  to  result,  and  an  irritable,  ragged 
ulcer  may  arise  from  the  pressure.  In  such  a  case,  the  prepuce 
should  be  slit  freely,  so  that  all  compression  may  be  avoided;  the 
lotion  of  dilute  nitric  acid  will  now  suffice  to  readily  heal  the 
abrasion. 

Echinacea  has  been  presented,  by  modern  Eclectic  physicians,  as 
a  remedy  for  syphilis.  My  experience  has  been  confined  to  its  use 
where  stubborn  pharyngeal  ulcers  have  manifested  an  irritable,  sensi- 
tive condition.  Here,  echinacea,  both  locally  and  constitutionally, 
produces  satisfactory  results.  Sometimes  the  local  use  of  galvan- 
ism is  useful  to  assist  in  healing  painful  and  stubborn  pharyugeal 
and  palatal  ulcers,  two  or  three  milliamperes  being  applied  to  the 
spot  with  the  negative  pole,  and  repeated  every  other  day. 

As  constitutional  remedies  for  this  disease,  additional  to  what 
have  already  been  mentioned,  may  be  named  chaidmoogra  oil,  which 
may  be  administered  in  ethereal  solution,  or  in  capsules. 

StiUingia  sylvatica,  in  the  form  of  a  green  plant  tincture,  combined 
with  iodide  of  potassium,  is  especially  recommended  in  tertiary 
syphilis.  Cfdoride  of  gold,  in  tertiary  syphilis  of  the  bones,  in  second 
decimal  trituration,  is  worthy  of  trial. 

Professors  Goss,  of  Georgia,  and  J.  W.  Hamilton,  of  California, 
are  enthusiastic  admirers  of  echinacea,  administered  in  from  thirty- 
to  sixty-drop  doses  of  a  saturated  tincture  of  the  fresh  root. 

XXVL  LEPROSY. 

Synonyms. — Lepra;  Elephantisis  Grsecorum;  Leontiasis. 

Definition. — A  chronic  infectious  disease,  caused  by  the  bacil- 
lus leprse,  characterized  by  tuberculous  growths  in  the  skin  and 
mucous  membranes,  and  areas  of  ansesthesia  and  destructive  ulcera- 
tion,  corresponding  to  the  distribution  of  nerves  which  become 
affected  by  the  development  of  the  bacilli  in  their  structures. 

Etiology. — Leprosy  is  a  disease  of  the  earliest  antiquity — 
known  to  the  earliest  writers.  It  prevails  along  the  shores  of  the 
Mediterranean  sea  extensively,  though  since  the  middle  ages  it  once 
nearly  disappeared  from  Europe,  except  in  Norway  and  the  Orient. 
On  the  Pacific  Coast,  the  disease  is  occasionally  found  among  Cau- 
casians, and  the  Chinese  are  frequently  affected.  The  Sandwich 
Islands  are  notoriously  affected,  there  being  over  a  thousand  lepers 
at  the  settlement  of  Molokai.  At  Tracadie,  N.  S.,  is  a  lazaretto,  in 


LEPROSY.  287 

which  are  confined  about  a  score  of  lepers,  the  disease  having  been 
introduced  by  emigrants  from  Normandy,  during  the  latter  part 
of  the  seventeenth  century.  The  number  of  persons  affected  is  dimin- 
ishing, the  settlement  having  formerly  contained  over  forty  mem- 
bers. It  is  most  liable  to  spread  in  hot  climates,  the  West  Indies, 
the  Gulf  States,  and  Mexico,  being  homes  of  quite  a  large  number 
of  lepers.  All  ages  and  all  classes  may  be  affected. 

The  exact  method  of  transmission  is  not  positively  known, 
though  it  is  generally  believed  that  th.e  disease  may  be  propagated 
by  sexual  congress.  It  certainly  is  not  very  contagious,  unless  there 
be  special  exposure,  for  healthy  persons  may  be  about  lepers  for 
years,  and  remain  uncontaminated.  Osier  states  that  not  one  of  the 
Sisters  of  Charity,  who  for  forty  years  have  nursed  the  lepers  of  Tra- 
cadie,  have  contracted  the  disease.  It  is  believed  to  be  hereditary. 

Dr.  Morrell  Mackenzie,  in  an  article  written  a  short  time  before 
his  death,  declared  that  leprosy  is  alarmingly  on  the  increase,  all 
over  the  world.  He  asserted  that  in  Spain  and  Portugal,  as  well  as 
in  other  parts  of  Southern  Europe,  the  disease  is  rapidly  gaining 
ground,  the  fact  being  due,  according  to  his  belief,  to  the  lax  pro- 
visions of  the  proper  authorities  for  isolating  those  affected.  He 
was  a  firm  believer  iii  the  contagiousness  of  the  affection,  and 
deplored  the  custom  of  so  mauy  of  regarding  it  as  non-contagious, 
since  such  belief  led  to  lack  of  proper  isolation  of  those  affected. 
Jonathan  Hutchinson  and  others  ascribe  the  complaint  to  diet, 
Hutchinson  believing  that  a  fish  diet  tends  to  its  production.  A 
large  contingent  scout  such  a  proposition,  however,  asserting  that 
there  are  many  facts  in  history  which  contradict  such  a  statement. 

The  bacillus  leprce  resembles  the  bacillus  tuberculosis  in  many 
respects,  though,  as  has  already  been  pointed  out  (in  the  Introduc- 
tion), there  is  a  distinction.  It  can  be  found  in  the  tuberculous 
structure  of  leprosy,  in  large  numbers,  though  it  does  not  propagate 
in  inoculation  tests  upon  animals,  thus  differing  decidedly,  in  one 
respect,  from  the  bacillus  tuberculosis. 

Pathology. — Like  tubercle,  the  tuberculous  growths  of  leprosy 
are  due  to  granulomatous  infiltration,  from  the  irritating  influence  of 
the  bacilli  upon  the  embryonal  cells  of  connective  tissue.'  The 
growth  involves  the  skin  later,  and  grows  outward,  tuberous  projec- 
tions forming  over  circumscribed  areas,  between  which  are  ulcera- 
tion  or  cicatrization.  These  give  rise  to  disfiguration  of  the  surface, 
und,  when  the  face  is  involved,  remarkable  distortion  of  the  features 
may  result.  Sometimes  deep  ulceration  may  further  disfigure  the 
part,  amputation  of  the  fingers  and  toes  thus  occasionally  resulting. 
When  the  bacilli  develop  in  the  substance  of  the  nerve-fibers,  there 


288  SPECIFIC  INFECTIOUS  DISEASES. 

is  more  or  less  destruction  of  their  functions,  and  peripheral  neuri- 
tis results,  with  localized  areas  of  anaesthesia,  and  trophic  changes 
in  the  skin.  The  bacilli  are  found  in  great  numbers  iimong  and 
within  the  cells  of  the  tuberculous  growths,  and  among  and  within 
the  affected  nerve-fibers. 

Symptoms. — Two  clinical  forms  are  described,  viz.,  tubercular 
leprosy,  aud  anaesthetic  leprosy : 

The  first  appearance  of  tubercular  leprosy  may  be  that  of  sharply 
defined  spots  upon  the  skin,  resembling  erythema  or  psoriasis.  Sen- 
sibility may  here  be  exalted,  at  first,  and,  after  a  time,  the  spots  may 
become  pigmented.  Anaesthesia  gradually  develops,  and  there  is 
either  a  gradual  outgrowth  of  tuberculous  nodules  over  the  surface, 
or  the  spots  gradually  fade  out,  becoming  perfectly  white  (lepra 
alba).  The  mucous  membranes  become  involved  gradually,  the  voice 
growing  hoarse  and  husky,  and  finally  being  entirely  lost,  from 
involvement  of  the  laryngeal  mucous  membrane;  and  death  may 
result  from  laryngeal  complications,  giving  rise,  later,  to  pneumonia, 
of  chronic  form.  The  eyebrows  and  eyelashes,  as  well  as  the  other 
hairs  of  the  face,  fall  out;  tuberculous  growths  may  form  upon  the 
conjunctivas,  resulting  in  blindness  from  leprous  keratitis,  and  the 
face  may  become  frightfully  thickened  and  distorted,  from  the  cuta- 
neous tubercular  outgrowths.  The  most  common  locations  of  the 
growths  are  the  face,  breast,  scrotum,  and  penis. 

Anaesthetic  leprosy  differs  materially  in  its  characteristics  from  the 
tuberculous  form,  though  due  to  the  same  cause.  Here  the  disease 
is  largely  confined  to  nerve-trunks,  while  its  outward  manifestations 
are  exhibited  upon  the  surface,  in  peripheral  results  of  disturbed  or 
arrested  sensory  or  trophic  functions.  The  earliest  symptoms  are 
pains  in  the  limbs,  and  areas  of  hypercesthesia,  anaesthesia,  or  numbness, 
upon  the  surface.  Maculae  or  pigment-spots  may  appear  upon  the 
trunk  and  extremities,  here  to  persist  for  a  time  and  afterward  dis- 
appear, leaving  localized  areas  of  anaesthesia.  Bullae  upon  the  sur- 
face may  denote  trophic  disturbances,  these  appearing,  in  some  cases, 
quite  early.  Enlargement  and  nodulation  of  superficial  nerve-trunks 
may  be  felt,  after  the  disease  has  progressed  for  a  time,  and  the 
trophic  disturbances  become  more  and  more  marked,  as  the  disease 
progresses.  Pemphigus-like  bullaa  form  and  break,  leaving  deep  and 
destructive  ulcers;  contractures  and  necroses  of  the  fingers  and  toes, 
and  other  destructive  changes,  follow.  The  changes  are  persistent 
and  gradual. 

Diagnosis. — The  macular  spots,  with  hyperaasthesia  and  sub- 
sequent anaesthesia,  will  suggest  the  character  of  the  disease  early. 
Later,  the  development  of  tuberculous  growths  on  the  face  and  other 


GLANDEKS.  289 

parts,  with  attending  symptoms,  could  hardly  be  mistaken;  and  the 
manifestations  of  anaesthetic  leprosy  are  about  as  positive. 

Prognosis. — As  there  has  not  yet  been  discovereda  cure  for  lep- 
rosy, and  the  tendency  is  continually,  though  slowly,  toward  a  worse 
condition,  the  prognosis,  as  to  a  cure,  must  necessarily  be  unfavor- 
able, though  life  may  not  be  materially  shortened  by  the  disease. 

Treatment. — The  treatment  of  leprosy  is  not  liable  to  bring 
laurels  to  the  attending  practitioner.  There  are  no  remedies  which 
produce  striking  results,  and  we  cannot  expect  to  do  more  than  lessen 
the  rapidity  of  its  progress.  Lepers  hardly  continue  treatment  long 
enough  to  give  any  remedy  a  fair  trial,  and  few  are  appreciably  bene- 
fited with  drugs.  Chaulmoogra  oil  and  gurjun  oil  have  been  recom- 
mended. Berberis  aquifolium  should  be  thought  of  favorably.  In 
any  case,  treatment  should  be  persisted  in  for  a  long  time — many 
months — if  improvement  is  to  be  expected. 

The  protection  of  the  uncontaminated  public  is  more  important 
than  the  cure  of  a  few  individual  cases.  Lepers  should  be  isolated 
and  confined,  so  that  the  disease  may  not  spread.  This  is  a  matter 
in  which  law-makers  in  all  civilized  countries  should  act  together, 
that  proper  lazarrettos  may  be  instituted,  where  such  subjects  can 
l>e  provided  for,  and  restricted  from  intercourse  with  the  world  at 
large. 

XXVII.    GLANDERS. 

Synonym. — Farcy. 

Definition. — A  specific,  infectious  disease  of  horses,  communi- 
cable to  man,  characterized  by  the  formation  of  nodules  of  granuloma- 
tous  tissue,  occurring  chiefly  in  the  nares  (glanders)  and  beneath  the 
skin  (farcy). 

Etiology. — The  cause  of  this  disease  is  a  short,  non-motile 
bacillus,  resembling  the  tubercle  bacillus,  which  enters  the  body 
through  an  abraded  surface,  either  of  the  skin  or  the  nasal  mucous 
membrane,  the  disease  usually  being  contracted  from  affected  horses, 
though  it  may  be  communicated  from  man  to  man,  washer-women 
having  been  inoculated  from  the  clothing  of  those  affected. 

Pathology. — The  disease  consists  in  the  formation  of  granu- 
lomatous  tumors,  of  low  vitality,  which  tend  to  early  breaking  down. 
They  are  composed  of  epithelioid  and  lymphoid  cells,  among  which  are 
found  the  bacilli — the  irritating  elements  which  provoke  the  morbid 
growth.  These  nodules  manifest  a  tendency  to  undergo  rapid 
destructive  changes,  which  result  in  ulceratioii  of  the  mucous  mem- 
brane and  deeper  structures  of  the  nose,  in  glanders,  and  in  abscesses 
beneath  the  skin,  in  farcy.  Internal  organs  sometimes  become 

30 


290  SPECIFIC  INFECTIOUS 'DISEASES. 

involved,    and    the  characteristic  nodules  are  then    found    in  their 
structure. 

Symptoms. — This  disease  may  occur  in  either  the  acute  or 
chronic  form,  both  these  occurring  in  the  nasal  and  subcutaneous 
varieties. 

When  the  nose  is  involved,  an  acute  attack  is  inaugurated  by  gen- 
eral febrile  disturbance,  with  redness,  swelling,  and  lymphangitis  at 
the  point  of  inoculation,  nodules  soon  forming  about  the  vicinity, 
which  break  down  a  few  days  later,  melting  away  in  a  profuse,  muco- 
purulent  discharge.  The  cervical  lymphatics  soon  become  swollen, 
hardened,  and  painful.  Associated  with  these  symptoms  is  a  cuta- 
neous eruption,  first  papular,  then  pustular,  which  appears  on  the 
face  and  about  the  joints,  resembling,  in  general  appearance,  the 
eruption  of  variola.  Severe  constitutional  symptoms  attend  the  local 
manifestations.  There  are  fever,  rapid  prostration,  and  typhoid 
symptoms,  the  disease  terminating  fatally  in  from  eight  to  ten  days. 
When  the  chronic  form  occurs,  the  symptoms  are  at  first  those  of  a 
severe  coryza.  There  is  ulceration  of  the  nasal  mucous  membrane, 
with  laryngeal  irritation  and  ulceration,  which  may  linger  for 
months,  recovery  finally  taking  place  in  some  cases,  though  a  fatal 
termination  usually  follows. 

When  the  skin  is  involved  in  acute  farcy,  there  is  severe  phleg- 
monous  inflammation  at  the  point  of  inoculation,  with  rapidly 
spreading  swelling,  the  lymphatics  becoming  involved,  and  nodules 
(farcy  buds)  forming  along  thoir  course.  These  soon  reach  a  stage 
of  suppuration,  and  abscesses  form  in  the  vicinity.  Pain  and  swelling 
occur  about  the  joints,  though  the  eruption  observed  in  the  nasal 
form  is  rarely  met.  Severe  constitutional  symptoms,  similar  to 
those  of  septicaemia,  rapidly  develop,  and  a  fatal  termination  is 
almost  inevitable,  within  twelve  or  fifteen  days.  Chronic  farcy  is 
more  gradual  in  its  inception,  and  it  is  characterized  by  the  presence 
of  localized  tumors,  usually  in  the  extremities.  These  break  down 
into  abscesses  and  form  deep  ulcers,  without  much  constitutional  dis- 
turbance. In  chronic  farcy,  the  lymphatics  are  not  usually  involved, 
and  the  disease  may  continue  for  months  or  years,  recovery  occa- 
sionally resulting  finally,  though  pyaemia  and  death  follow  more 
frequently.  Sometimes  acute  glanders  may  result  from  auto-inocu- 
lation. 

Diagnosis. — The  diagnosis  will  not  be  difficult,  the  severity  of 
nasal  glanders  distinguishing  it  from  all  other  forms  of  nasal  trouble, 
unless  the  chronic  form  occur.  Here,  it  may  be  necessary  to  submit 
some  of  the  discharge  to  a  bacteriologist,  for  culture  and  other 
inspection.  The  history  of  the  case,  the  "farcy  buds,"  and  early  sub- 


ACTINOMYCOSIS.  291 

cutaneous  abscesses  of  acute  farcy,  can  hardly  be  mistaken  for  any 
other  disease,  especially  when  the  history  of  the  case  will  usually 
afford  evidence  of  exposure  to  infection  from  a  diseased  horse,  at  a 
recent  date. 

Prognosis. — The  prospects  of  recovery  from  acute  glanders  or 
farcy  are  exceedingly  doubtful,  and  the  prognosis  must  be  almost 
invariably  unfavorable.  Recovery  from  chronic  glanders  and  farcy 
sometimes  occurs,  and  there  may  be  some  hope  offered,  though  even 
here  there  is  little  prospect  of  a  favorable  termination.  It  is  said, 
however,  that  the  noted  French  veterinary  surgeon,  Bouley,  recov- 
ered from  an  attack  of  chronic  farcy. 

Treatment. — Prophylaxis  is  the  important  part  of  treatment, 
because  restorative  treatment  is  not  attended  by  very  promising 
results.  If  the  point  of  inoculation  can  be  discovered  early,  it  is 
advised  to  excise,  or  destroy  it  with  caustics.  Farcy  buds  should  be 
opened  early,  and  thoroughly  drained,  with  local  antisepsis.  Inter- 
nally, we  may  derive  pome  benefit  from  the  persistent  use  of  echina- 
cea  or  berberis  aquifolium,  preference  being  given  to  echinacea  in 
acute  cases,  and  to  berberis  aquifolium  in  chronic  ones.  In  acute 
attacks,  either  of  nasal  glanders  or  farcy,  little  Mope  can  be  offered, 
though  this  need  not  deter  us  from  trying  the  best  Eclectic  remedies 
in  our  possession. 

XXVin.  ACTINOMYCOSIS. 

Synonyms. — Big-jaw;  Lumpy-jaw. 

Definition. — A  specific  infectious  disease  of  cattle,  pigs,  horses, 
and  other  animals,  communicable  to  man,  caused  by  the  ray  fungus 
(actinomyces). 

Etiology. — The  actinomyces  is  a  fungus,  consisting  of  micro- 
scopic threads,  radiating  from  a  common  center,  bearing,  on  their  ends, 
bulbous  or  club-like  terminations.  Infection  prob- 
ably occurs  from  feeding,  as  the  tissues  about  the 
jaws  are  usually  affected  first,  though  the  disease 
may  originate  in  the  intestines,  lungs,  brain,  or 
skin.  It  is  believed  that  barley  or  rye  may  con- 
tain the  fungus,  and  be  a  source  of  the  disease 
among  cattle,  if  not  men.  Doubtless  diseased  flesh 
also  conveys  it  to  man.  It  is  asserted  that  the 
.  fungus  may  gain  entrance  through  abrasions  in  the 
skin  and  mucous  membranes,  and  through  cavities  in  decayed  teeth. 

The  disease  is  rare. 

Pathology.— The  pathological  change  consists  in  a  convei 
of  mature  connective  tissue  into  a  granulomatous  mass,  composed  of 


292  SPECIFIC  INFECTIOUS  DISEASES. 

ronnd  and  epithelioid  cells,  with  occasional  giant  cells,  the  growth, 
in  its  early  condition,  resembling  that  of  ordinary  tubercle.  After 
a  time,  however,  there  begins  a  rapid  growth  of  the  tumors,  owing 
to  active  proliferation  of  the  connective  tissue  in  the  neighborhood, 
the  morbid  condition  then  much  resembling  sarcoma,  in  its  general 
appearance.  Suppuration  begins  later,  and  the  pus  contains  yellow 
particles,  visible  to  the  naked  eye.  The  growth  now  becomes  bur- 
rowed with  fistulous  sinuses  and  scattering  abscesses.  Chronic 
inflammation  of  the  surrounding  tissues  attends,  though  the  lym- 
phatics do  not  become  involved.  The  later  course  of  the  disease 
resembles  that  of  a  malignant  tumor. 

Symptoms. — These  vary,  to  correspond  with  the  location  of  the 
morbid  growth.  If  the  fact  is  primarily  affected,  an  irregular,  nod- 
ulated swelling  will  involve  the  cheeks,  jaws,  temples,  tongue,  or 
some  contiguous  part,  with  slow  and  painless  enlargement,  at  first, 
though  it  will  take  on  a  rapid  growth  later.  When  suppuration 
begins,  and  irregular  fever  attends,  the  condition  resembles  that  of 
chronic  pyaemia.  Septic  symptoms  may  be  prominent,  and  the 
symptoms  may  simulate  those  of  typhoid  fever.  When  the  lungs 
are  involved,  cough  will  be  a  prominent  feature,  and  the  disease 
will  run  a  course  similar  to  that  of  some  cases  of  pulmonary  tuber- 
culosis, or  fcetid  bronchitis.  When  the  skin  is  involved,  nodular 
excrescences  appear  upon  the  surface,  which  ultimately  ulcerate,  and 
pass  through  a  protracted  period  of  suppuration,  the  ulcers  stub- 
bornly remaining  for  years,  thus  bearing  a  resemblance  to  tuberculo- 
sis of  the  skin.  When  the  brain  is  the  part  affected,  symptoms  of 
cerebral  tumor  are  manifest  Epileptic  symptoms,  unsteadiness  of 
gait,  and  mental  disturbance,  in  the  beginning,  with  delirium  and 
coma,  later  on,  are  liable  to  appear.  When  the  intestines  are  involved, 
gastro-intestinal  disturbance  will  be  prominent. 

The  disease  may  involve  parts  distant  from  the  face,  secondarily, 
there  then  being  a  complication  of  the  disturbance  about  the  face 
with  the  various  visceral  troubles. 

Diagnosis. — The  presence  of  the  actinomyces  in  the  pus  will 
be  the  distinctive  diagnostic  feature,  though  when  the  location  of  the 
affection  is  in  its  usual  part,  about  the  face,  the  general  picture  and 
peculiar  course  will  be  highly  suggestive.  The  yellow  particles  in 
the  pus,  often  visible  to  the  naked  eye,  demonstrated,  upon  micro- 
scopical examination,  to  be  actinomyces,  will  settle  the  question. 

Prognosis. — Wherever  the  disease  is  located,  there  is  always 
liability  of  secondary  infection.  Its  course  is  likely  to  resemble, 
clinically,  that  of  sarcoma,  and  it  almost  invariably  goes  on  to  a  fatal 
termination.  However,  when  the  disease  is  restricted  to  the  skin, 


INFECTIOUS  DISEASES  OF  DOUBTFUL  NATURE.          293 

or  is  located  so  superficially  as  to  permit  of  surgical  interference 
without  involving  vital  parts,  recovery  may  follow  early  treatment. 
Treatment. — The  treatment  is  principally  surgical  If  the  dis- 
ease be  located  where  it  can  be  exposed,  the  surgeon's  knife  should 
be  called  into  service,  to  eradicate  every  vestige  of  the  morbid 
growth.  When  the  case  progresses  to  suppuration,  the  treatment 
pursued  in  pysemia  is  all  that  can  be  offered. 

XXIX.  INFECTIOUS  DISEASES  OP  DOUBTFUL  NATURE. 

SIMPLE  CONTINUED  FEVER. 

Synonyms. — Febricula;  Synocha;  Synochoid. 
Definition. — An  infectious  fever,  usually  of  short  duration  and 
favorable  prognosis. 

Description  and  Etiology. — In  non-malarious  districts,  dur- 
ing the  absence  of  epidemics  or  endemics,  febrile  affections  occur, 
which  arise  from  colds,  retained  secretions,  errors  in  diet,  excessive 
mental  or  physical  effort,  exposures  to  the  sun,  or  other  accidental 
cause,  outside  of  any  known  specific  infection,  which  may  be  classed 
under  this  name.  There  is  no  regular  or  stated  course  of  continu- 
ance, in  this  class  of  fevers,  the  gravity  of  the  cause,  the  constitu- 
tional resistance  of  the  patient,  or  the  treatment,  determining  the 
period  of  duration.  In  some  cases,  the  fever  will  terminate  in  a 
day  or  two,  while  in  others,  it  may  continue  for  from  ten  days  to 
three  weeks. 

Sometimes  the  system  is  in  such  a  predisposing  condition  that 
the  fever  assumes  quite  a  serious  aspect,  and  takes  on  a  high  grade 
of  temperature  and  pulse-rate,  the  maximum  temperature  reaching 
as  high  as  106°  for  several  days,  and  the  pulse  running  at  a  rapid 
rate,  full  and  bounding.  Such  patients  possess  powerful  reactive 
constitutions,  and  the  course  of  the  fever  is  actively  inflammatory  in 
its  characteristics,  tending  to  inflammation  of  the  lungs  or  brain,  if 
it  does  not  terminate  within  the  first  week.  This  character  of  feb- 
rile manifestation  has  been  described  as  a  separate  form,  under  the 
name,  "synochal  fever."  After  this  time,  typhoid  symptoms  grad- 
ually appear,  and  delirium  and  blood  depravation,  as  manifested  Ly 
the  condition  of  the  tongue,  develop.  Or,  typhoid  symptoms  may 
appear  early  in  the  course  of  the  disease,  within  the  first  two  or 
three  days,  and  the  temperature  may  run  a  course  much  like  that  of 
typhoid  fever,  during  the  fastigium,  the  prostration,  nervous  symp- 
toms, and  blood  depravation  simulating  that  disease  very  much, 
though  the  fever  may  terminate  within  two  weeks,  usually,  under 


294  SPECIFIC  INFECTIOUS  DISEASES. 

rational  treatment.     This  form  has  been  described  by  some  writers 
under  the  term,  "synochoid,"  or  "common  continued  fever." 

Symptoms. — The  disease  usually  begins  with  an  abrupt  rise 
in  temperature,  the  stage  of  invasion  only  occupying  the  first  day, 
or  a  few  hours.  The  temperature  may  rise  as  high  as  102°,  103°, 
104°,  105°,  or  106°,  during  the  evening,  but,  if  the  fever  lasts  over 
the  second  day,  there  is  a  morning  remission  of  one  or  two  degrees, 
each  day.  Where  the  temperature  is  very  high,  the  form  known  as 
synocha  may  develop,  and  the  disease  run  for  a  week,  the  pulse  being 
full  and  bounding,  respiration  hurried,  and  the  patient  restless  and 
wakeful.  There  is  headache  during  this  stage,  the  eyes  are  bright, 
the  urine  is  scanty,  and  perspiration  is  arrested,  the  skin  being 
hot  and  dry,  the  bowels  constipated,  and  the  appetite  absent. 
The  patient  is  usually  more  restless  and  uncomfortable  during  the 
after  part  of  the  day  and  early  part  of  the  night,  morning  hours 
being  attended  by  subsidence  of  the  more  aggravated  symptoms. 
Continuing  in  this  way  for  five  or  six  days,  favorable  cases  terminate 
suddenly,  by  rapid  lysis,  or  crisis ;  secretion  becomes  established,  the 
urine  flows  freely,  the  skin  becomes  moist  and  cool,  the  pulse  normal, 
and  respiration  easy  and  natural,  the  headache  subsides,  and  the 
appetite  returns. 

If  the  fever  does  not  abate  at  this  time,  and,  also,  if  there  has 
been  considerable  of  a  period  of  incubation,  the  symptoms  from  the 
start  may  assume  a  typhoid  character.  This  constitutes  the  form 
known  as  synochoid,  or  common  continued  fever.  When  so  from  the 
beginning,  there  is  usually  a  marked  chill,  following  several  days  of 
depression.  Though  not  so  severe  as  an  ague,  the  patient  will  com- 
plain of  coldness  of  the  extremities,  and  of  chilly  sensations,  creep- 
ing over  the  body.  These  are  soon  alternated  with  flushes  of  heat, 
until  febrile  action  is  well  established.  Now  we  begin  to  note  the 
typhoid  symptoms.  The  tongue  is  soon  coated;  the  coating  may  be 
pasty  white  or  it  may  be  yellowish,  or  there  may  be  a  tendency  to 
an  irritable  condition  of  the  stomach,  as  indicated  by  the  elongated 
tongue,  with  reddened  tip  and  edges.  Whatever  the  condition  of 
the  tongue  in  the  commencement,  it  is  liable,  in  the  later  stages,  to 
be  either  clean  and  slick,  with  dark  red  mucous  membrane,  or  the 
coating  to  become  brown  and  dirty.  In  bad  cases,  there  may  be 
sordes  on  the  teeth  and  lips.  The  pulse  is  now  small  and  feeble, 
and  the  patient  is  liable  to  develop  considerable  disturbance  of  the 
cerebral  centers,  as  manifested  by  dreamy  delirium,  or  coma-vigil. 
While  this  condition  resembles  that  of  typhoid  fever,  in  many 
respects,  there  is  usually  absence  of  diarrhoea,  tympanites,  and  other 
abdominal  symptoms  characteristic  of  true  typhoid.  Pulmonary 


INFECTIOUS  DISEASES  OF  DOUBTFUL  NATURE.         295 

complication  often  attends  protracted  cases  of  this  fever,  and,  occa- 
sionally, serious  cerebral  congestion. 

Diagnosis. — The  su'dden  onset  and  early  decline  of  the  fever, 
without  complication,  will  enable  one  to  readily  diagnose  the  simpler 
cases.  Where  typhoid  symptoms  appear,  and  the  disease  becomes 
protracted,  there  will  be  an  absence  of  the  serious  abdominal  symp- 
toms that  characterize  true  typhoid.  The  rash  of  typhoid  fever  will 
also  assist  in  clearing  up  a  doubtful  diagnosis.  It  should  be  recol- 
lected that  typhoid  fever  occurs  as  an  epidemic  or  endemic,  and  that 
sporadic  cases  can  seldom  be  supposed  to  exist,  while  the  opposite 
is  true  of  this  form.  Where  it  is  necessary  to  render  a  diagnosis  in 
obscure  or  doubtful  cases,  microscopical  inspection  of  the  supply  of 
drinking  water  and  milk,  and  the  evacuations,  may  assist  in  clearing 
up  the  obscurity. 

Prognosis. — There  is  little  danger  of  a  fatal  termination,  even 
in  the  most  aggravated  form,  if  judicious  management  be  observed. 
Though  the  synochoid  form  may  present  some  aggravated  features, 
proper  treatment  if  ill  usually  correct  them  in  good  season,  and  a 
favorable  termination  in  all  cases,  except  those  of  great  debility  or 
extreme  age,  ensues. 

Treatment. — Abbreviated  cases  of  febricula  require  little  treat- 
ment, more  than  that  which  will  render  the  patient  less  uncomfort- 
able. Small  doses  of  aconite  and  gelsemium  may  be  employed  to 
lessen  the  height  of  the  fever,  and  a  full  dose  of  bromo-seltzer  may  be 
administered,  if  there  is  severe  headache.  Cooling  lotions  may  be 
applied  to  the  head,  and  mildly  acid  drinks  administered,  until  the 
attack  passes  off. 

The  synochal  form  will  demand  the  use  of  jdborandi,  as  follows : 
9  Sp.  m.  jaborandi  ^iii,  water  fiv.  M.,  and  give  a  teaspoonful  every 
hour,  until  the  fever  declines.  When  the  pulse  is  bounding,  with 
other  gelsemium  indications,  that  agent  may  be  preferred.  An  alkaline 
sponge  bath,  administered  every  day,  or  a  cold  abdominal  wet  pack, 
will  assist  in  reducing  the  fever,  with  safety  to  the  patient. 

The  synochoid  form  may  be  treated  as  a  case  of  typhoid  fever. 
Sometimes  the  indication  for  some  special  antiseptic  will  be  pro- 
nounced, and  the  important  part  of  the  treatment  will  consist  in  sup- 
plying this  demand.  For  more  definite  instruction  here  the  reader 
is  referred  to  the  general  treatment  of  fevers,  in  the  Introduction. 

WEIL'S  DISEASE. 

Synonyms. — Acute  Infectious  Jaundice;  Bilious  Typhoid  of 
Griesinge"r. 

Definition. — An    infectious    disease,  characterized    by  marked 


296  SPECIFIC  INFECTIOUS  DISEASES. 

jaundice,  high  fever,  severe  pains  in  the  extremities  and  back,  and 
albuminuria,  with  termination,  in  from  ten  to  twelve  days,  by  lysis. 

Etiology. — The  exciting  factor  of  this  disease  is  unknown.  It 
is  most  liable  to  occur  in  hot  weather,  among  males  between  twenty 
and  forty  years  of  age,  and  is  especially  liable  to  affect  butchers, 
these  facts  suggesting  that  exposure  to  putrefactive  exhalations  from 
animal  and  vegetable  decomposition  may  exert  a  causal  influence. 
Mild  epidemics  may  occur. 

Pathology. — Little  is  known  of  the  morbid  anatomy  of  this 
disease,  as  it  seldom  proves  fatal.  The  symptoms  suggest  obstruct- 
ive jaundice  and  renal  irritation.  There  is  evidently  splenic 
engorgement,  detected  by  palpation  during  the  course  of  the  disease. 
The  kidneys  are  congested,  with  acute  parenchymatous  degeneration 
of  the  histological  elements. 

Symptoms. — The  onset  is  abrupt,  there  being  a  chill  or  suc- 
cession of  rigors  followed  by  high  fever,  the  temperature  .rapidly 
rising  to  104°  or  105°,  and  the  pulse  to  100  or  110  per  minute.  The 
fever  is  remittent,  and  remains  high  for  about  the  first  week,  when 
it  declines  by  lysis,  terminating  about  the  tenth  or  twelfth  day.  The 
jaundice  appears  early,  often  on  the  second  day,  the  icteric  hue 
being  deep  yellow,  in  the  skin  and  conjunctive,  the  tongue  being 
loaded  with  a  yellowish  fur.  There  is  nausea,  disgust  for  food,  and 
sometimes  vomiting,  in  the  beginning,  and  a  diarrhoea  of  clay-colored 
stools  is  liable  to  appear  later.  Severe  headache,  thirst,  backache, 
and  pains  in  the  extremities  mark  the  exacerbations,  while  the 
remissions  are  attended  by  little  amelioration.  Bile,  along  with 
albumin,  is  present  in  the  urine.  As  the  disease  progresses,  it 
becomes  less  active,  and  the  patient  is  finally  prostrated,  and  may 
manifest  more  or  less  marked  typhoid  symptoms. 

In  about  one-fourth  of  the  cases,  a  relapse  occurs  six  or  seven 
days  after  the  return  to  normal,  the  temperature  again  rising,  as  in 
relapsing  fever.  The  relapse  is  mild,  however,  and  only  lasts  five 
or  six  days.  Convalescence  is  slow  and  tedious,  sometimes  occupy- 
ing two  or  three  months. 

Diagnosis. — The  symptoms  of  jaundice  occur  too  early  for  that 
which  sometimes  arises  in  relapsing  fever,  and  the  history  of  the 
case  will  usually  distinguish  between  this  disease  and  that.  In 
typhus  fever  the  jaundice  also  occurs  later,  while  the  rash  of  that 
disease,  about  the  sixth  or  seventh  day,  is  characteristic.  The  his- 
tory of  the  case,  and  the  markedly  epidemic  character  of  typhus,  will 
assist  in  distinguishing  it. 

Prognosis. — This  is  almost  universally  favorable,  few  cases 
resulting  fatally. 


INFECTIOUS  DISEASES  OF  DOUBTFUL  NATURE.         297 

Treatment. — The  treatment  will  be  adapted  to  each  particular 
case.  To  Control  the  fever  and  assist  in  eliminating  the  morbid 
elements  from  the  system,  the  properly  selected  sedative  should  be 
administered  every  hour,  during  the  first  week,  at  least.  Where 
there  is  nausea  with  indications  of  gastric  irritability,  aconite  and 
r h us  should  be  given:  R  Green  plant  tincture  of  rhus  tox.  gtt  xv, 
Lloyd's  aconite  gtt.  v— vii,  water  fiv.  M.,  and  order  a  teaspoonful 
every  hour.  Or,  where  there  is  less  tendency  to  nausea,  more  pro- 
nounced sedatives  may  be  employed.  R  Specific  jaborandi  jii-iii, 
water  fiv.  M.,  and  order  a  teaspoonful  every  hour.  Determination 
of  blood  to  the  brain  will  call  for  gdsemium,  and  capillary  congestion 
for  belladonna.  In  connection  with  the  sedative,  or  alternated  with 
it,  the  following  should  be  administered  every  two  hours,  in  tea- 
spoonful  doses :  #  Sp.  m.  polymnia  ji,  sp.  m.  chionanthus  jss,  sp.  m. 
chelidonium  ji,  water  fiv.  If  the  tongue  is  .heavily  loaded  with  a 
dirty,  yellowjsh- white  coating,  sulphite  of  sodium  should  be  given,  in 
one-grain  doses,  every  three  or  four  hours,  until  the  coating  has  disap- 
peared. A  bland  and  nutritious  diet  should  be  allowed  during  con- 
valescence, and  some  appropriate  bitter  tonic  should  stimulate  the 
recuperative  functions,  attention  being  especially  paid  to  the 
demands  of  a  malarious  district 


MILK  SICKNESS. 

Definition. — A  disease  supposed  to  be  communicated  to  man 
from  eating  the  flesh  or  drinking  the  milk  of  cattle  affected  by 
what  is  commonly  known  as  "trembles." 

Etiology. — This  disease  formerly  prevailed  among  the  early 
settlers  of  the  states  bordering  on  the  western  slope  of  the  Alleghany 
Mountains.  Cattle  and  sheep  were  subject  to  a  peculiar  nervous 
affection  called  trembles,  characterized  by  refusal  of  food,  injec- 
tion of  the  eyes,  and  staggering  gait,  with  trembling  of  the  muscles, 
and,  finally,  death  in  convulsions.  The  cause  of  this  disease  has  been 
supposed  to  be  some  form  of  plant-food  taken  with  the  wild  herbage, 
the  disease  having  gradually  disappeared,  as  clearing  up  of  the  for- 
ests, and  cultivated  fields,  have  been  the  order.  In  some  sections  of 
North  Carolina,  it  still  prevails.  When  milchers  are  affected,  it 
is  said  that  they  may  not  manifest  the  disease  unless  overdriven, 
the  poison  lurking  in  the  milk  and  proving  fatal  to  those  con- 
suming it.  Sheep,  as  well  as  domestic  cattle,  may  be  affected,  their 
flesh,  as  well  as  that  of  beeves,  proving  poisonous  when  eaten.  It 
is  said  that  an  ounce  of  butter  or  cheese  from  an  affected  cow,  or 
four  ounces  of  beef,  raw  or  cooked,  three  times  daily,  will  prove 


298  SPECIFIC  INFECTIOUS  DISEASES. 

fatal  to  a  dog,  within  six  days.  Nothing  definite  is  known  respect- 
ing the  specific  principle  of  the  disease. 

Pathology. — Little  has  been  recorded  of  the  pathology  of  this 
affection,  as  few  scientific  investigations  by  autopsies  have  been 
made.  Doubtless  the  principal  lesions  will  be  found  in  the  ali- 
mentary canal  and  cerebro-spinal  centers. 

Symptoms. — The  symptoms  of  the  disease  in  man  are  charac- 
terized by  two  or  three  days  of  prodromes,  such  as  restlessness  and 
gastric  discomfort,  followed  by  acute  pain  in  the  stomach,  with  nau- 
sea and  vomiting,  thirst,  and  fever,  which  rapidly  passes  into 
typhoid  symptoms,  the  tongue  becoming  swollen  and  tremulous,  the 
breath  foetid,  the  bowels  constipated,  and  the  urinary  secretion  more 
or  less  diminished.  There  is  great  restlessness  and  irritability  at 
first,  but  this  may  give  way  to  coma  and  convulsions.  Death  may 
occur  in  three  or  four  days,  or  the  disease  may  run  three  or  four 
weeks. 

Diagnosis. — The  rapid  onset  of  the  disease,  with  the  violent 
gastro-intestinal  irritation  and  nervous  symptoms,  will  suggest  its 
presence,  in  sections  where  it  is  likely  to  prevail. 

Prognosis. — The  disease  has  fortunately  become  rare,  as  it  is 
nearly  always  fatal  in  its  results.  The  profound  poisoning  seems  to 
defy  the  best  treatment  that  has  yet  been  tried. 

Treatment. — Opiates  should  be  avoided,  and  remedies  admin- 
istered to  control  the  vomiting.  Bismuth,  and  aconite  and  rhus  tox, 
may  be  tried,  for  this  purpose.  When  the  vomiting  has  been 
arrested,  echinacea  should  be  administered  freely.  Passiftora  and 
lackesis  may  also  be  thought  of. 

MALTA  FEVER. 

Synonyms. — Mediterranean  Fever;  Neapolitan  Fever;  Bock 
Fever. 

Definition. — A  febrile  disease,  which  prevails  at  the  Island  of 
Malta,  Naples,  and  other  points  about  the  Mediterranean  Sea,  char- 
acterized by  an  initiatory  attack  of  mild  febrile  action  of  about  a 
week's  length,  followed  by  a  remission  of  two  or  three  days,  with 
a  prolonged  relapse  of  increased  severity  and  persistent  duration, 
during  which  gastro-intestinal,  pulmonary,  cardiac,  and  arthritic 
disturbances  are  liable  to  develop. 

Etiology. — The  nature  of  this  disease  is  yet  in  dispute,  it  being 
generally  denied  that  it  is  due  to  malaria.  Some  have  asserted  that 
it  is  typho-malarial  fever,  there  being  marked  febrile  exacerbations 
and  remissions;  but  it  does  not  yield  to  quinine,  and  does  not  behave 
like  ordinary  malarial  fever.  An  examination  of  the  blood  will  fully 


INFECTIOUS  DISEASES  OF  DOUBTFUL  NATURE.         299 

settle  the  question.  Some  have  contended  that  it  is  typhoid  fever, 
but  there  is  absence  of  the  characteristic  lesions  of  that  disease. 
Rheumatic  symptoms  are  sometimes  present,  and,  catarrhal  manifes- 
tations being  prominent,  it  may  be  due  to  atmospheric  influences. 
Sewer-gas  has  been  suggested  as  a  possible  causal  factor,  though  it 
is  doubtful  if  any  one  has  yet  named  the  proper  one. 

Pathology. — There  is  irritation  of  the  gastro-intestinal  and  pul- 
monary mucous  membranes,  with  enlargement  and  congestion  of  the 
spleen,  endocarditis,  and  effusion  into  the  joints  and  other  serous 
cavities. 

Symptoms. — In  the  commencement,  the  symptoms  may  resem- 
ble those  of  mild  quotidian  ague,  though  usually  the  invasion  is  more 
insidious,  and  the  patient  may  be  unable  to  name  the  day  upon  which 
his  illness  began.  Anorexia,  lassitude,  drowsiness,  and  slight  head- 
ache are  the  first  symptoms  here,  and  these  gradually  advance,  until 
there  is  nausea,  vomiting,  and  diarrhoea,  a  few  days  later.  Febrile 
symptoms  alternated  with  chilliness  now  appear,  and  the  severity 
of  the  symptoms  increases  day  by  day.  Severe  frontal  headache  has 
developed  by  this  time,  and  the  patient  is  sleepless,  restless,  nau- 
seated and  thirsty,  constantly.  In  about  a  week,  in  mild  cases,  these 
symptoms  abate,  and  the  patient  supposes  himself  convalescent,  and 
goes  about  his  duties.  In  two  or  three  days  however  the  old  symp- 
toms return,  with  increased  severity.  The  nausea  and  vomiting  are 
more  aggravated,  and  there  is  active  diarrhoea,  this  sometimes 
amounting  to  dysentery,  with  severe  tenesmus  and  the  evacuation  of 
muco-sanguineous  stools.  Again,  there  may  be  symptoms  of  pneumo- 
nia, with  cough  and  rusty  sputum.  In  other  cases,  the  prominent 
symptom  may  be  that  of  excruciating  pain  in  the  back  or  one  of  the 
extremities,  which  is  so  severe  as  to  prevent  motion.  There  is  steady 
loss  of  flesh,  anaemia  comes  on  with  loss  of  hair,  enlargement  of  the 
spleen  and  liver,  and  the  patient  slowly  drags  through  a  protracted 
convalescence,  with  extreme  debility.  The  febrile  symptoms  are 
marked  by  periodicity,  with  evening  exacerbations  and  morning 
remissions. 

Treatment. — The  treatment  should  be  in  accordance  with  the 
suggestions  in  the  general  treatment  of  fevers  given  in  the  Introduc- 
tion. Hygienic  precautions  should  be  especially  observed. 

MIUABY  FEVER. 

THIS  disease,  which  is  otherwise  termed  "sweating  sickness," 
prevailed  in  various  parts  of  Europe  and  England  during  the  fifteenth 
and  sixteenth  centuries,  but  it  has  been  confined,  during  later  times, 
to  certain  districts  in  France  and  Italy.  When  it  occurs,  large 


300  SPECIFIC  INFECTIOUS  DISEASES. 

numbers  of  persons  are  attacked  at  once,  the  disease  spreading  rap- 
idly, like  influenza.  The  disease  is  characterized  by  fever,  profuse 
perspiration,  and  an  erythematous  eruption  surmounted  by  a  crop 
of  miliary  vesicles.  Severe  cases  are  attended  by  determination  of 
blood  to  the  brain  and  active  delirium  at  first,  with  prostration  and 
coma  later  on.  Death  sometimes  occurs  in  a  few  hours,  the  outset 
of  epidemics  often  being  attended  by  a  high  death-rate. 

MOUNTAIN  FEVEB. 

A  SEVERE  form  of  fever  prevails  in  elevated  regions  of  the  Rocky 
Mountains,  to  which  this  term  is  applied.  Two  varieties  are 
described,  one  a  continued,  and  the  other  a  periodical  form,  either 
intermittent  or  remittent  In  the  continued  form,  the  character- 
istic lesions  of  true  typhoid  fever  are  found,  and  in  the  period- 
ical type  the  early  manifestations  are  those  of  malaria,  with  later 
development  of  the  typhoid  element  It  is  asserted  that  the  severe 
form  of  mountain  fever  is  more  liable  to  prove  fatal  than  typhoid 
fever  in  lower  altitudes;  that  treatment  is  less  effective  in  such  ele- 
vated regions  than  nearer  sea  level,  delirium,  stupor,  and  extreme 
destruction  of  tissue  in  the  intestines  rapidly  advancing  to  a  fatal 
issue.  Dr.  Hayes,  formerly  of  Denver,  Colorado,  several  years  ago 
reported  success  in  the  treatment  of  this  fever  with  echinacecu 


SEQTION  III, 

CONSTITUTIONAL  DISEASES. 


I.  RHEUMATISM. 

Definition. — A  constitutional  disease,  characterized  by  pain 
and  tenderness  in  the  locomotor  apparatus,  including  the  joints  and 
muscles,  with  tendency  to  endocarditis  and  acid  sweats. 

Etiology. — Considerable  confusion  exists  regarding  the  etiology 
of  rheumatism.  The  latest  theory  is  that  it  is  due  to  the  presence 
of  microorganisms  in  the  blood,  and  some  authors  class  it  as  a  spe- 
cific infectious  disease.  But,  while  various  microbes  have  been  found 
in  the  blood  of  rheumatic  persons,  there  does  not  seem  to  be  any 
one  that  is  constantly  present.  Defective  dissimilation  has  been 
ascribed  as  the  cause  by  Prout  and  his  *  followers,  upon  the  ground 
that  lactic  acid  or  one  of  its  compounds  results  from  the  faulty 
appropriation  of  the  food,  and  that  this  irritates  the  various  tissues 
of  the  locomotor  apparatus.  However,  clinical  and  therapeutical 
experience  has  proven  this  theory  to  be  wrong,  as  acids  instead  of 
alkalies  sometimes  prove  curative,  and,  in  the  majority  of  cases,  sim- 
ple vegetable  agents  prove  more  curative  than  either  acids  or  alka- 
lies. Many  regard  the  disease  as  a  catarrhal  condition,  the  causes 
which  produce  colds  with  irritation  of  the  pulmonary  or  other 
mucous  membranes  being  directed  to  the  locomotor  apparatus 
instead,  and  provoking  the  various  unpleasant  effects  observed  here. 
Such  disturbances  may  be  trophic  in  character,  from  impressions 
reflected  from  the  central  nervous  system;  or,  they  possibly  originate 
morbid  secretions,  such  as  lactic  acid,  through  influences  exerted 
upon  the  sympathetic.  One  fact  is  established,  and  that  is,  that  the 
disease  prevails  to  the  greatest  extent  in  temperate,  humid  sections, 
where  sudden  changes  of  temperature  from  warm  to  cold  are  com- 
mon— where  exactly  the  conditions  prevail  which  predispose  to 
catarrhal  affections.  While  rheumatism  is  more  common  in  Eng- 
land and  Canada  than  in  the  United  States,  it  grows  less  common 
here  as  advance  is  made  toward  the  equator,  and,  in  such  dry  and 
elevated  regions  as  Arizona,  severe  cases  are  almost  unknown.  It  is 
quite  common  along  the  sea  coast  of  central  California,  but  much  less 
so  in  the  more  arid  regions  of  the  southern  interior. 

There  seem  to  be  certain  predisposing  causes,  such  as  debility 
from  over-work,  bad  food,  and  other  unsanitary  conditions,  tending 
to  bring  it  on  upon  slight  provocation.  Malarial  attacks  are  liable 


302  CONSTITUTIONAL  DISEASE& 

to  be  complicated  with  rheumatism,  and  rheumatism  may  follow  an 
attack  of  malaria  and  prove  very  stubborn,  the  malarial  anaemia 
becoming  much  aggravated  by  the  rheumatic  condition. 

The  cla^s  of  persons  affected  oftenest  is  that  which  comprises  the 
robust  and  middle-aged  male  population,  which  is  exposed  most  to 
vicissitudes  of  weather.  Still,  every  age  and  condition  may  suf- 
fer from  it,  though  the  disease  is  rare  among  very  young  chil- 
dren. Laborers,  sailors,  drivers,  bakers,  iron-workers,  and  others 
liable  to  sudden  chilling  of  the  surface  when  over-heated,  or  to  wet- 
ting in  the  cold  rain,  are  those  most  commonly  subject  to  acute  rheu- 
matism. Heredity  is  believed  to  exert  a  certain  influence,  it  being 
observed  that  the  members  of  certain  families  are  especially  prone 
to  rheumatic  attacks,  this  probably  being  due  to  hereditary  suscep- 
tibility. The  disease  presents  itself  in  various  forms,  and  the  follow- 
ing varieties  will  be  considered  separately  : 

ACUTE  ABTICULAR  RHEUMATISM. 

Synonyms. — Acute  Rheumatism;  Inflammatory  Rheumatism; 
Rheumatic  Fever. 

Definition. — An  acute,  non-contagious  fever,  characterized  by 
severe  inflammation  and  swelling  of  one  or  more  of  the  joints,  with 
puffiuess  and  tenderness,  and  tendency  to  metastasis. 

Etiology. — This  has  already  been  sufficiently  discussed  under 
the  general  head.  Inflammatory  rheumatism  usually  occurs  during 
the  spring  and  winter  months,  when  dampness  and  sudden  changes 
prevail. 

Pathology. — The  changes  which  occur  are  not  especially  char- 
acteristic of  this  disease,  more  than  of  any  other  inflammatory  con- 
dition. In  many  cases  where  there  has  been  remarkable  enlarge- 
ment of  the  joints  and  excruciating  pain,  no  structural  change  can  be 
detected  after  death.  In  other  cases,  there  are  hypersemia  and 
enlargement  of  the  synovial  membranes  and  ligaments,  with  turbid- 
ity of  the  synovial  fluid,  which  contains  leucocytes  and  third  corpus- 
cles. If  the  heart  be  involved,  the  ordinary  conditions  of  carditis 
are  found,  and  other  inflammatory  complications  present  the  usual 
appearances  of  inflammation  of  this  part  There  is  an  unusual 
amount  of  fibrin  in  the  blood.  Suppuration  of  affected  parts  is  rare, 
unless  there  be  secondary  complications,  such  as  pleurisy,  pericar- 
ditis, or  periostitis.  One  attack  predisposes  to  subsequent  ones. 

Symptoms. — There  may  be  anorexia,  dyspepsia,  malaise,  and 
wandering  pains,  for  two  or  three  days  prior  to  the  actual  onset, 
though  these  are  often  absent,  the  attack  then  being  abrupt.  A  chill 
or,  more  commonly,  chilly  sensations  announce  the  commencement  of 


RHEUMATISM.  303 

the  attack.  The  temperature  now  rises  quickly,  the  thermometer 
indicating  an  elevatioii  of  from  103°  to  104°  F.,  within  twenty-four 
hours;  the  tongue  is  coated,  there  are  headache  and  often  pain  and 
soreness  in  the  throat.  The  pulse  is  full  and  soft,  and  running  at 
100  per  minute.  The  skin  is  often,  though  not  always,  moist  and 
frequently  covered  with  a  sour  sweat.  The  urine  is  scanty,  and,  on 
standing,  it  deposits  urates  abundantly.  Miliaria  often  appear  upon 
the  surface,  and  sometimes  a  pronounced  roseolous  eruption  is  pres- 
ent. Simultaneously  with  the  onset  of  the  fever,  changes  in  one  or 
more  of  the  joints  appear.  There  may  be  swelling  and  puffiness  at 
first,  without  redness  or  pain,  but  pain  soon  becomes  excruciating, 
and  the  swollen  part  is  reddened  and  exceedingly  tender  to  the  touch, 
the  weight  of  the  bedclothes  being  oppressive.  THe  large  joints 
are  most  apt  to  be  involved,  such  as  the  knee,  ankle,  shoulder,  wrist, 
and  elbow,  though  the  fingers  and  toes  may  be  implicated.  Some- 
times nearly  all  the  joints  of  the  body  may  be  involved,  even  the 
vertebral  articulations,  the  sterno-clavicular  joint,  the  synchondroses 
of  the  ribs  and  symphysis  pubis,  and  the  sacro-iliac  synchondrosis 
also.  The  joints  of  the  ary  tsenoid  cartilages  have  been  thus  affected. 

A  marked  feature  is  a  tendency  to  subsidence  of  the  inflamma- 
tion in  one  joint,  with  simultaneous  appearance  of  swelling,  pain, 
and  redness  in  another  (metastasis). 

Anaemia  rapidly  develops  as  the  disease  continues,  and  the  acid 
sweats  become  neutral  or  alkaline.  Endocarditis  is  liable  to  develop, 
an  apex  bruit  being  now  detectable. 

The  fever  declines  by  gradual  lysis  in  favorable  cases,  though 
the  disease  may  continue  for  weeks  when  badly  managed,  permanent 
stiffness  and  deformity  of  the  joints  remaining  as  a  result  of  inflam- 
matory deposits  about  their  structures. 

In  malarial  districts,  a  marked  periodicity  may  become  manifest, 
the  pain  being  paroxysmal,  or  marked  exacerbation  may  occur  every 
day,  or  every  second  day. 

There  is  usually  little  mental  disturbance,  the  patient  being  con- 
scious and  rational,  and  thus  capable  of  appreciating  his  sufferings 
intensely,  unless  free  use  is  made  of  opiates,  in  which  event  delir- 
ium may  be  present.  Sometimes  internal  organs  other  than  the 
heart  are  involved,  the  bladder  sometimes  being  severely  affected, 
producing  dysuria,  with  severe  tenesmus,  or  complete  ischuria 
requiring  catheterization. 

Diagnosis. — The  severe  joint-symptoms,  with  tendency  to 
metastasis,  will  distinguish  this  disease  from  others.  Pyaemia,  where 
the  joints  are  affected,  may  resemble  it  at  first,  but  suppurative 
synovitis  follows  in  pyaemia,  and  not  in  acute  articular  rheum  a- 


304  CONSTITUTIONAL  DISEASES. 

tism.  Arthritis,  not  rheumatic  in  character,  remains  persistently  in 
one  joint,  while  metastasis  occurs  in  rheumatism,  more  than  one 
joint  is  apt  to  be  involved,  and  cardiac  symptoms  may  develop. 

Prognosis. — Properly  treated,  few  cases  of  rheumatism  ought 
to  result  fatally,  and  perfect  use  of  the  joints  ought  to  follow  recov- 
ery. The  principal  danger  is  in  cardiac  complication,  and  this  can 
usually  be  controlled  promptly  by  Eclectic  methods.  The  disease 
usually  lasts  three  or  four  days  in  one  joint,  and  it  may  con- 
tinue three  or  four  weeks,  in  obstinate  cases,  though  it  will  usually 
subside  much  earlier.  Ulcerative  endocarditis  sometimes  remains 
after  an  attack  of  rheumatism,  and  fatal  results  follow  at  a  more  or 
less  early  date.  Endarteritis,  pleurisy,  pneumonia  and  other  pul- 
monary affections,  meningitis,  and  peritonitis  may  follow  as  sequelae. 
Chorea  also  occasionally  develops,  while  subacute  or  chronic  rheu- 
matism may  remain  after  the  acute  attack  has  passed  off. 

Treatment. — We  possess  a  number  of  effective  remedies  for 
inflammatory  rheumatism,  and  only  need  to  adapt  them  correctly  to 
be  speedily  successful,  in  the  majority  of  cases.  The  alcoholic  vapor 
bath,  or  what  is  better  when  it  can  be  obtained,  the  cabinet  vapor 
bath,  is  excellent  and  will  often  succeed  alone  in  effecting  a  perfect 
cure  in  two  or  three  days'  time.  The  application  should  be  thorough 
enough  each  time  to  promote  profuse  perspiration,  and  should  be 
repeated  every  day,  and  aided,  when  practicable,  by  the  tonic  faradic 
treatment.  To  assist  this,  or  as  an  independent  measure,  two  full 
doses  of  specific/o&orandi  will  be  found  excellent,  from  twenty  to  thirty 
drops  being  given  two  hours  apart,  the  following  prescription  being 
administered  every  hour  afterward  until  recovery,  unless  it  becomes 
necessary  to  abandon  it  in  two  or  three  days  for  other  means :  #  Sp. 
m.  jaborandi  $iii,  water  fiv.  M.  Dose,  a  teaspoonfuL 

If  there  be  any  special  indication  of  blood  depravation  this 
should  be  met  in  the  meantime,  in  order  that  special  treatment  may 
not  be  embarrassed.  Sometimes  there  is  excessive  acidity  of  the 
stomach  with  septic  complication,  indicated  by  the  creamy,  or  dirty- 
white  coating  on  the  tongue,  and  salts  of  sodium  may  be  demanded. 
Here  we  may  derive  benefit  from  the  salicylate  of  sodium,  using  a 
three-grain  capsule  every  three  or  four  hours.  Usually,  however, 
the  sulphite  of  sodium  will  correct  the  septic  condition  better,  though 
it  is  not  so  specifically  adapted  to  the  rheumatic  condition.  Occa- 
sionally, there  may  be  lack  of  acids,  indicated  by  the  dark  red 
mucous  membrane  and  slick  tongue,  calling  for  twenty-drop  doses 
of  dilute  muriatic  acid,  to  be  repeated  every  four  hours  until  the  spe- 
cific condition  has  been  corrected. 

When  such  measures  fail  to  effect  a  speedy  impression,  the  best 


RHEUMATISM.  305 

remedy  to  rely  upon  is  rhamnus  californica,  wine-glassful  doses  of  a 
strong  decoction  of  the  bark,  or  twenty-  or  thirty-drop  doses  of  the 
extract  being  administered  every  three  or  four  hours  until  free 
catharsis  is  established,  and  afterward  continued  in  small  doses,  just 
short  of  catharsis.  This  remedy  will  seldom  fail  to  bring  about  sat- 
isfactory results  in  a  few  days.  A  combination  which  has  afforded 
me  good  results  in  past  time  is:  R  Sp.  m.  cimicifuga  jii,  wine 
of  colchicum  seed  f  ss,  spts.  nit.  dul.  fi,  simple  elixir,  ad.  fiv.  S. 
Take  a  teaspoonful  every  three  hours.  Phenacetin  sometimes  brings 
relief,  and  is  worthy  of  trial  in  stubborn  cases.  A  capsule  consist- 
ing of  phenacetin  gr.  iii,  caulophyllin  gr.  l-10th,  and  arseniate  of 
quinia  3x  gr.  ii,  is  my  favorite  form  for  administration,  one  being 
the  dose,  to  be  repeated  every  two  hours  until  profuse  perspiration 
follows. 

The  general  propositions  which  apply  to  the  treatment  of  fevers 
may  be  applied  in  the  treatment  of  rheumatism.  The  irritable  stom- 
ach will  cull  for  aconite  and  rhus  tooc.;  periodicity  for  antiperiodio 
doses  of  quinine,  etc. 

Opiates  should  generally  be  avoided,  as  their  action  is  calculated 
to  prolong  the  disease  and  increase  the  liability  to  serious  cardiac 
complication. 

Blisters  should  be  employed  sparingly,  if  at  all.  Sometimes, 
when  severe  cardiac  complication  seems  to  threaten  vital  action,  a 
large  fly-blister,  applied  to  the  left  pectoral  region,  may  produce  a 
desirable  derivative  effect. 

Local  applications  to  the  inflamed  joints  may  sometimes  be  of 
satisfactory  service,  and,  as  the  sufferer  will  usually  demand  them, 
they  must  not  be  forgotten.  Diluted  chloroform  is  probably  the 
best  application,  an  ounce  to  four  of  alcohol  being  used  to  moisten 
wrappings  of  cotton,  which  should  be  covered  with  flannel  band- 
ages wrung  as  dry  as  possible  from  hot  water.  A  favorife  applica- 
tion with  old  school  physicians,  though  not  very  effective,  is  turpen- 
tine, applied  freely,  the  parts  being  afterward  enveloped  in  raw 
cotton.  Various  anodyne  liniments  have  their  respective  advocates. 

The  diet  should  be  carefully  regulated,  meat  and  stimulants  being 
strictly  prohibited  during  the  febrile  stage.  A  milk  or  bread-and- 
milk  diet  is  sufficient  during  this  time,  enough  being  allowed  to 
satisfy  the  demands  of  the  appetite;  or,  if  there  be  anorexia,  milk 
should  be  administered  in  small  quantities  every  two  or  three  hours. 
When  milk  cannot  be  taken  (and  many  spleen  against  it),  soups  and 
broths  may  be  allowed  instead.  Oyster  soup,  clam  broth,  oat- 
meal gruel,  etc.,  are  appropriate  substitutes.  Such  drinks  as  vichy 
or  seltzer  may  be  taken,  though  plain  w.iter  is  proper,  or,  where 
21 


306  CONSTITUTIONAL  DISEASES. 

craved  by  the  patient,  lemonade,  dilate  celery  phosphate,  barley 
water,  or  rice  water  may  be  drunk  freely.  It  is  well  to  avoid  sac- 
charine food,  both  during  the  disease  and  during  convalescence,  the 
diet  of  convalescence  being  restricted,  at  first,  to  rice,  arrowroot,  oat- 
meal, corn  meal,  unsweetened  puddings,  soup,  wine  jelly,  blanc-mange, 
and  malted  foods.  The  return  to  animal  diet  should  be  gradual,  and 
only  after  the  fever  has  subsided  for  at  least  a  week.  Then  the 
yolks  of  eggs,  boiled  an  hour  (one  each  day),  fish,  sparingly  at  first, 
oysters,  and  the  white  meat  of  broiled  or  roasted  chicken  may  be 
taken,  along  with  cooked  celery,  spinach,  asparagus,  etc.  Baked 
apples,  or  pears,  without  sugar,  may  be  allowed,  but  sugar  and  alco- 
hol should  be  avoided  for  weeks,  as  they  are  liable  to  provoke  a 
relapse. 

SUBACUTB  ARTICULAR  KHEUMATISM. 

This  form  of  rheumatic  disease  may  follow  an  attack  of  acute 
rheumatism,  or  it  may  occur  in  an  individual  who  has  formerly  suf- 
fered an  acute  attack  and  afterward  been  exposed  to  some  exciting 
cause  of  the  trouble.  The  pathology  is  similar  to  that  of  the  acute 
form,  except  that  the  joint  affection  leaves  no  trace  of  disorganiza- 
tion, though  there  are  similar  blood  changes.  There  is  not  the  mor- 
bid tendency  to  metastasis  that  characterizes  acute  rheumatism,  and 
the  joints  do  not  become  reddened  and  swollen,  nor  are  they  painful, 
unless  moved  or  strained.  Only  one  or  two  joints  may  be  involved. 
Anaemia  is  a  manifest  symptom,  and  cardiac  complications  are  liable 
to  occur.  The  disease  may  come  on  gradually,  in  some  cases,  with- 
out a  previous  history  of  acute  rheumatism.  There  is  little  or  no 
fever.  The  condition  may  persist  for  from  six  or  seven  weeks  to 
three  or  four  months. 

The  treatment  consists  in  the  steady  use  of  rhamnus  californica, 
and  the  daily  application  of  thorough  massage  about  the  affected 
joint  or  joints.  The  rhamnus  californica  should  be  prepared  by  boil- 
ing a  drachm  of  the  recent  bark  for  twenty  minutes  over  a  slow  fire 
(after  it  has  been  infused  in  a  pint  of  cold  water),  from  one  to  two 
tablespoonfuls  being  administered  four  or  five  times  daily.  Where 
but  one  joint  is  affected  the  patient  may  be  able  to  apply  the  mas- 
sage himself,  and  then  he  should  knead  the  affected  part  vigorously 
and  thoroughly,  several  times  each  day.  This  will  be  found  very 
effective. 

The  diet  should  be  unstimulatiug,  milk  being  preferable.  Per- 
sons subject  to  rheumatism  should  wear  fiannel  underclothing 
throughout  the  year. 


KHEUMATISM.  307 

CHRONIC  ARTICULAR  BHEUMATISM. 

Synonym. — Chronic  Rheumatism. 

Definition. — A  chronic,  articular  disease  of  advanced  life,  char- 
acterized by  thickening  of  the  capsules  and  ligaments  of  the  joints, 
without  marked  deformity,  the  disease  being  aggravated  by  damp- 
ness and  atmospheric  changes. 

Etiology. — This  is  a  disease  which  comes  on  after  middle  life, 
either  insidiously  or  as  a  sequela  of  former  attacks  of  acute  or  sub- 
acute  rheumatism.  Damp  localities  predispose  to  it,  such  as  dark 
and  damp  dwellings,  sleeping  in  ground-floor  apartments,  or  over 
damp  cellars,  etc.  It  is  aggravated  during  the  winter  and  spring, 
and  the  joints  are  rendered  stiff  and  lame  from  prolonged  rest, 
motion  and  exercise  tending  to  relieve  them  for  a  time.  It  is  most 
common  among  those  of  laborious  occupation.  Such  persons  are 
usually  good  "weather  prophets,"  as  they  are  susceptible  to  atmos- 
pheric changes,  and  are  usually  influenced  in  advance  of  the  advent 
of  a  marked  change  of  weather.  Sometimes  only  one  large  joint 
may  be  affected,  though  several  are  usually  involved  at  the  same 
time. 

Pathology. — In  some  cases  there  is  no  structural  change,  the 
syuovial  structures  being  injected,  but  not  much  altered  other- 
wise, there  not  being  much  effusion.  Usually,  in  long-standing 
cases,  the  fibrous  tissue  around  the  joints,  the  fibrous  envelope  of 
the  nerves,  the  fascise,  the  peritoneum,  and  the  aponeurotic  sheaths 
of  the  muscles  are  all  involved  in  chronic  inflammation.  There  is 
thickening  as  well  as  increased  vascularity  of  the  synovial  mem- 
branes, the  fringe-like  processes  are  enlarged,  and  the  synovial  fluid 
is  turbid.  Sometimes  there  are  erosions  of  the  articular  surfaces. 
Deformities  may  arise  from  the  formation  of  constricting  bands  of 
fibrous  material  about  the  diseased  joints,  and  the  deformity 
may  be  more  prominent  from  atrophy  of  the  surrounding  mus- 
cles, through  local  disease  or  from  reflected  trophic  influences. 
Cardiaccomplications  are  seldom  present 

Symptoms. — The  symptoms  come  on  gradually,  slight  soreness 
and  stiffness  of  the  affected  joints  being  first  noticed  during  damp 
and  cloudy  weather,  or  on  the  day  following  some  severely  laborious 
occupation.  This  is  more  noticeable  upon  rising  in  the  morn- 
ing, and  it  gradually  disappears  as  the  affected  part  becomes 
accustomed  to  action.  The  affection  becomes  more  troublesome 
during  sudden  changes,  and  in  the  cold  and  damp  months  of 
winter  aud  spring.  The  joints  gradually  become  more  impeded 
in  their  range  of  motion,  finally  being  painful  when  at  rest 
There  is  usually  slight  tenderness  upon  pressure,  but  the  joints  are 


301  CONSTITUTIONAL  DISEASES. 

only  slightly  swollen  and  not  reddened,  unless  there  be  extreme 
aggravation.  Suffering  is  usually  increased  at  night  and  ameliorated 
by  exercise  in  the  morning.  Stiffness,  soreness,  and  impairment  of 
the  joints  slowly  increase  with  advancing  age,  though  there  is  never 
marked  deformity  nor  serious  loss  of  motion.  The  large  joints  are 
usually  involved,  though  the  finger-joints  may  be  affected  in  those 
who  use  the  hands  severely,  such  as  washerwomen. 

Diagnosis. — This  affection  should  not  be  confounded  with 
arthritis  deformans,  for  here  there  is  marked  deformity  of  the  joints, 
almost  complete  loss  of  motion,  and  gradual  progress  from  one  joint 
to  another,  with  never  any  improvement,  while  weather  changes  exert 
no  influence  upon  it.  There  is  also  pronounced  deformity  in  gout, 
and  the  small  joints  are  the  parts  affected. 

Prognosis. — While  not  inimical  to  longevity,  the  prognosis,  as 
to  a  cure,  is  not  favorable,  unless  the  patient  be  removed  to  a  new 
and  healthful  climate.  However,  when  proper  treatment  is  begun 
early  and  persevered  in,  the  severity  of  the  disease  may  be  much 
modified.  After  structural  changes  have  gone  on  in  the  joints,  palli- 
ation of  the  most  distressing  symptoms  is  the  best  that  we  can  hope 
for  -  without  radical  change  of  climate. 

Treatment. — Early  in  the  disease,  massage  and  electricity  will 
be  of  good  service.  Both  faradism  and  galvanism  are  useful,  strong 
currents  of  each  being  passed  through  the  affected  part  or  parts, 
alternated  at  every  sitting  (every  two  or  three  days). 

Rhatnnus  calif ornica  is  now  of  some  use,  and  it  should  be  persisted 
in  for  months,  alone,  or  combined  with  grindelia  squarrosa  if  the 
neighborhood  be  malarious.  The  patient  should  dress  the  year 
round  in  warm  flannels,  to  prevent  chilling  of  the  joints  from  draughts 
and  dampness,  and  avoid  a  catting,  so  far  as  possible,  requiring  much 
outlay  of  muscular  effort.  The  diet  should  be  nutritious,  but  red 
meat  should  be  generally  avoided,  the  patient  being  instructed  to 
depend  upon  fish,  eggs  and  fowl,  avoiding  sweets  and  alcoholic 
drinks,  the  basis  of  his  diet  consisting  of  farinaceous  food,  with  a 
few  fresh  vegetables. 

Aggravations  should  be  met  appropriately.  Periodical  aggrava- 
tions will  call  for  proper  antimalarial  treatment.  Active  inflamma- 
tory aggravation  of  a  particular  joint  may  be  benefited  by  blistering 
the  part.  Chloroform  liniment  may  relieve  the  pain  at  night.  In 
other  cases,  warm  or  cold  applications  afford  more  relief. 

Patients  of  competent  means  should  be  advised  to  spend  their 
winters  in  a  warm  climate,  southern  Europe,  southern  California,  or 
Arizona  offering  prospects  of  greater  comfort  than  ordinary  climates. 
There  are  certain  thermal  springs  that  afford  much  benefit  to  these 


RHEUMATISM.  309 

patients,  such,  for  instance,  as  the  Hot  Springs  of  Arizona  or  Vir- 
ginia, Byron  Springs,  near  San  Francisco,  or  those  of  Banff,  in  the 
Rocky  Mountains,  etc. 

MUSOULAB  RHEUMATISM. 

Synonym. — Myalgia. 

Definition. — A  painful  disease  of  the  muscles  and  their  fasciae, 
as  well  as  of  the  periosteum,  arising  from  constitutional  influences. 

Etiology. — Sudden  chilling  after  exertion,  overstrain  of  the  mus- 
cles, protracted  exposure  to  dampness,  and  malaria  are  among  the 
exciting  causes.  It  is  most  commonly  met  with  in  those  who  apply 
themselves  to  severe  bodily  exertion,  and  is  apt  to  follow  draughts 
of  air,  wetting  from  chilling  rains,  etc.  Rheumatic  or  gouty  per- 
sons are  most  subject  to  attacks,  and  they  may  be  seized  during 
changeable  weather,  without  undue  exposure. 

Pathology. — Investigations  into  the  pathology  of  this  disease 
have  thrown  little  light  upon  the  subject.  The  muscles  undergo  few 
if  any  anatomical  changes,  and  such  changes  are  not  constant.  Occa- 
sionally there  may  be  evidence  of  inflammation  of  the  sheaths  of  the 
muscles,  or  scanty  serous  exudation  into  their  substance,  and,  at  other 
times,  signs  of  degeneration  of  the  muscular  fibers.  Sometimes 
thickening  or  degeneration  of  the  neurilemma  of  the  nerves  supply- 
ing the  part  may  be  observed. 

Symptoms. — Many  attacks  of  muscular  rheumatism  occur  sud- 
denly. "  Crick-in-the-back "  is  an  illustration  of  this,  the  person, 
in  apparently  the  best  of  health,  being  suddenly  seized  with  an  excru- 
ciating pain  in  the  lumbar  region,  so  severe  as  to  give  rise  to  intense 
suffering  upon  the  least  attempt  at  motion.  Severe  attacks  of  pleu- 
rodynia  also  occur,  in  which  the  body  is  drawn  toward  the  affected 
side,  and  breathing  is  accompanied  by  intens'e,  lancinating  pains. 
lu  malarial  regions,  muscular  rheumatism  is  very  apt  to  be  periodi- 
cal, the  attacks  occurring  in  re'gular  exacerbations,  every  day  or 
every  second  day,  with  remissions  or  complete  intermissions  between. 
Sack  attacks  may  pass  off  in  a  few  days,  or  may  turn  into  a  chronic 
form,  the  pain  becoming  permanently  located  in  some  muscle  or 
group  of  muscles  and  causing  almost  constant  discomfort.  Some- 
times the  muscular  structures  of  the  internal  organs,  such  as  the 
stomach,  intestines,  bladder,  oesophagus,  etc.,  may  be  involved,  the 
functions  of  these  parts  then  being  impaired,  while  a  painful  state 
of  the  part  exists  simultaneously.  The  disease  is  almost  purely 
local,  little  febrile  or  other  systemic  disturbance  being  present. 

Localization  of  the  pain  in  various  regions  has  given  origin  to  a 
number  of  special  names  for  this  affection,  such  as  lumbago  (lumbar 


310  CONSTITUTIONAL  DISEASES. 

rheumatism),  torticollis  (stiff  neck),  and  pleurodynia  or  rheumatism 
of  the  intercostal  or  other  muscles  of  the  chest,  those  of  one  side 
usually  being  involved.  Sometimes  the  abdominal  muscles  are  dis- 
tinctly involved,  giving  rise  to  severe  cramping  pains  in  this  region. 

Diagnosis. — The  characteristic  symptoms  of  muscular  rheuma- 
tism will  usually  distinguish  it,  metastasis  being  a  symptom  not  com- 
mon to  any  other  painful  disease  of  the  muscles.  The  periosteal 
pains  of  syphilis  will  be  distinguished  by  the  fact  that  changes  of 
weather  do  not  affect  them  appreciably,  and  the  accompanying  symp- 
toms of  syphilis  will  afford  additional  light  on  the  subject.  Lumbago 
might  be  mistaken  for  renal  colic,  but  it  is  to  be  remembered  that 
lumbar  pain  in  lumbago  renders  motion  painful  and  difficult,  while 
in  renal  colic  the  patient  moves  about  in  all  positions  during  the 
paroxysm,  and  the  pain  darts  along  the  ureter  of  the  affected  side, 
the  corresponding  testicle  often  being  retracted,  while  the  urine  is 
scanty  and  probably  bloody.  In  spinal  pain,  pressure  upon  the  spin- 
ous  processes  causes  increased  suffering  while  lateral  pressure  is 
not  painful,  the  opposite  being  the  case  in  lumbago.  Pleurodynia  is 
often  diagnosed  as  pleurisy.  It  should  be  remembered  that  pleurisy 
is  attended  by  fever  and  cough  with  friction  sounds  on  ausculation, 
while  in  intercostal  rheumatism  the  principal  symptoms  are  pain 
and  dyspnoea,  while  motion  of  the  affected  muscles  aggravates. 
Abdominal  rheumatism  may  be  mistaken  for  peritonitis,  but  the 
absence  of  fever  and  the  severe  constitutional  symptoms  attending 
this  disease  will  clear  up  any  obscurity.  Trichinosis  is  attended  by 
pains  which  resemble  those  of  muscular  rheumatism,  but  here  there 
is  oedema  of  the  feet,  and  the  history  of  the  case,  usually  occurring 
in  several  individuals  simultaneously,  with  microscopical  examina- 
tion, will  settle  any  question  of  this  character. 

Prognosis. — There  is  no  danger  of  a  fatal  termination  of  this 
disease,  though  it  is  quite  liable  to  return  upon  slight  provocation. 
An  acute  attack  may  be  relieved  in  a  few  hours,  though  when  neg- 
lected it  may  become  chronic  and  prove  very  troublesome. 

Treatment. — To  relieve  an  attack  of  muscular  rheumatism,  the 
alcoholic  or  steam  vapor  bath  answers  an  admirable  purpose.  Some- 
times an  extremely  severe  case  may  be  advantageously  relieved,  in 
the  start,  with  a  l-4th  grain  dose  of  morphine,  either  hypodermically 
or  per  mouth,  though  the  use  of  opiates  is,  as  a  rule,  to  be  avoided, 
as  they  seem  to  finally  fix  the  disease  in  the  system  and  render  it 
more  stubborn.  The  vapor  bath  may  be  assisted  by  two  or  three 
wine-glassful  doses  of  a  hot  decoction  of  cimici/uga  root,  taken  every 
twenty  minutes  or  half-hour. 

Periodicity  should  be  expected  in  malarious  regions,  and  a  return 


PSEUDO-RHEUMATIC  AFFECTIONS.  311 

of  the  attack  be  anticipated  within  one  or  two  days,  appropriate 
doses  of  quinine  or  arseniate  of  quinia  being  administered. 

As  a  specific  remedy,  cimicifuga,  in  tablespoonful  doses  of  a  cold 
decoction,  may  be  continued  for  several  days,  every  three  or  four 
hours,  or,  where  desirable  to  employ  smaller  doses,  the  specific 
medicine  or  a  saturated  tincture  of  the  root  may  be  used,  by  adding 
half  a  drachm  to  four  ounces  of  water.  A  combination  of  aconite 
and  cimicifuga  (Scudder)  answers  well,  the  prescrfption  being  as 
follows:  $  Lloyd's  aconite  gtt.  v-vii,  green  plant  tincture  cimici- 
fuga gtt.  xx,  water  fiv.  M.,  and  order  a  teaspoonful  every  hour. 

Where  cimicifuga  fails,  where  the  tongue  is  coated  yellow,  or 
where  there  is  habitual  constipation,  rhamnus  californica  may  be 
used,  a  decoction  (ji  to  the  pint  of  water),  in  double-tablespoonful 
doses,  being  preferred  to  any  alcoholic  preparation.  The  dose 
should  be  reduced  if  too  free  action  on  the  bowels  follows. 

When  the  pain  becomes  localized  and  remains  stubbornly, 
the  following  prescription,  continued  for  a  fortnight,  will  often 
result  in  a  cure:  $  Phenacetin  gr.  iii,  caulophyllin  gr.  l-10th, 
arseniate  of  quinia  3x  gr.  ii.  M.,  ft.  capsule  110.  1.  Duplicate  no.  60. 
Sig.,  Take  one  every  four  hours.  The  prolonged  use  of  this  capsule 
may  result  in  profuse  and  and  prolonged  perspiration,  the  subse- 
quent use  of  two-grain  doses  of  picrotoxin  3x,  four  times  daily,  being 
required  to  control  it.  Massage  is  of  much  assistance  in  chronic 
cases,  the  muscles  gaining  tone  and  energy  under  its  influence,  and 
being  thus  enabled  to  better  resist  disease  agencies. 

In  chronic  cases,  we  will  rely  upon  this  agent  in  connection  with 
the  prolonged  use  of  rhamnus  calif  ornica  or  manacaf  occasional  alter- 
nation of  these  remedies  being  advisable.  Manaca  may  be  adminis- 
tered in  from  two-  to  five-drop  doses  (fl.  ext.)  four  or  five  times  daily. 

In  malarious  districts,  much  advantage  will  attend  the  continued 
use  of  fluid  extract  grindelia  squarrosa  (P.  D.  &  Co.),  in  ten-  or  fif- 
teen-drop doses,  three  or  four  times  a  day,  in  connection  with  the 
antirheumatic. 

The  diet  should  be  similar  to  that  recommended  under  the  treat- 
ment of  articular  rheumatism. 

II.  PSEUDO-RHEUMATIC  AFFECTIONS. 

ARTHRITIS  DEFORMANS. 

Synonyms. — Rheumatoid  Arthritis;  Rheumatic  Gout. 

Definition. — A  progressive,  destructive  disease  of  the  joints, 
characterized  by  inflammation  and  degeneration  of  the  cartilages 
and  synovial  membranes,  with  the  development  of  bony  growths 


312  CONSTITUTIONAL  DISEASES. 

upon  the  articular  surfaces,  and   thickening  of   the   ligaments  and 
other  soft  parts,  rendering  the  joints  immobile  and  deformed. 

Etiology. — Though  formerly  believed  to  be  closely  related  to 
both  rheumatism  and  gout,  there  is  a  rapidly  growing  belief,  among 
pathologists,  that  no  connection  exists  with  either,  in  the  causes  or 
nature  of  this  affection.  The  pathology  differs  essentially  from  both 
that  of  rheumatism  and  gout,  there  being  no  blood  changes  as  in 
rheumatism,  and  no  urate  of  soda  deposits  as  in  gout.  The  symp- 
toms, iu  the  start,  may  so  closely  resemble  those  of  chronic  articu- 
lar rheumatism  as  to  render  the  distinction  difficult,  but  this  is  prob- 
ably a  matter  of  diagnostic  obscurity  rather  than  of  similarity  of 
nature.  It  is  asserted  that  several  facts  tend  to  confirm  a  nervo- 
trophic  theory.  Of  these  may  be  mentioned  the  similarity  of  the 
affection  to  joint  diseases  due  to  affections  of  the  cord,  as  in  locomo- 
tor  ataxia;  the  apparent  origin  of  the  disease  from  shocks,  mental 
worry,  etc.;  the  tendency  to  symmetrical  distribution  of  the  lesions, 
and  changes  in  the  muscles,  skin,  and  nails,  evidently  due,  in  great 
measure,  to  trophic  influences.  It  is  asserted  that  damp  dwellings 
and  insufficient  and  improper  food  predispose  to  it,  though  it  seems 
to  be  an  assumption  rather  than  an  established  fact.  Heredity  may 
exert  some  influence,  though  the  disease  is  so  rare  that  a  family 
record  over  a  protracted  period  must  be  necessary  to  arrive  at  defi- 
nite conclusions.  It  is  more  common  in  females  than  in  males,  and 
the  small  joints  are  most  liable  to  be  involved  in  this  sex,  males 
being  more  subject  to  involvement  of  the  large  articulations.  The 
elderly,  the  middle-aged,  and  the  young  may  be  affected,  though  the 
period  between  twenty  and  thirty  is  the  age  most  susceptible. 

Pathology. — The  articular  cartilages  and  synovial  membranes 
suffer  the  earliest  and  most  marked  changes,  though  the  ligaments 
and  muscles  undergo  prominent  alterations  later  on.  The  artic- 
ular cartilages  become  softened  and  villous  in  the  center,  where  the 
greatest  pressure  is  exerted,  and  gradually  wear  away,  until  the  extrem- 
ities of  the  bones  are  exposed,  these  then  becoming  eburnated.  and 
constituting  the  articular  surfaces.  The  circumferences  of  the  car- 
tilages remain  and  undergo  irregular  nodulated  proliferation,  ossifi- 
cation setting  in  later,  the  bony  nodosities  (osteophytes)  serving  to 
lock  the  motion>  of  the  joints.  Meantime,  the  fringes  of  the  synovial 
membranes  become  increased  in  number  and  hypertrophied,  from 
augmented  vascularity,  and  later  undergo  fibrous  degeneration,  the 
whole  membrane  thus  becoming  thickened  and  hardened.  New  bone 
may  also  spring  up  from  the  periosteum,  and  the  joint  gradually 
becomes  locked  with  bony  growths,  and  firmly  bound  with  thickened 
bands,  the  ligaments,  as  well  as  the  synovial  membranes .  becoming 


PSEUDO-KHEUMATIC  AFFECTIONS. 


313 


hardened  and  thickened,  until  the  joint  is  finally  almost  immovable. 
The  muscles  atrophy  at  length,  and  both  hypertrophy  and  atrophy 
occur  about  the  expanded  extremities  of  the  bones,  varying  deform- 
ities thus  arising.  The  nerves  about  the  joint  may  participate,  a 
chronic  neuritis  becoming  established. 

Symptoms. — This  disease  may  be  divided  into  two  general 
forms,  viz.,  acute  and  chronic.  The  acute  form  may  be  divided  into 
two  varieties,  the  nodosities  of  Heberden,  and  the  general  progress- 
ive form. 

The  nodosities  of  Heberden  are  usually  confined  to  the  fingers,  the 
disease  becoming  arrested  after  involving  these  parts.  The  tubercles 
at  the  sides  of  the  dorsal  surfaces  of  the  second  phalanges  become 
slowly  enlarged,  slightly  reddened,  and  the  affected  joints  are  easily 
hurt  by  accidental  knocks,  though  not  usually 
painful.  The  cartilages  may  become  soft,  and 
the  extremities  of  the  bones  bared  later.  The 
joints  gradually  become  more  and-more  stiffened 
and  disfigured,  until  all  use  of  the  affected  part  is 
lost,  the  patient  meantime  enjoying  good  health 
otherwise.  This  form  is  most  common  among 
'women. 

The  general  progressive  form  may  come  on 
suddenly,  with  acute  symptoms,  or  it  may 
develop  by  a  chronic  course.  Acute  attacks 
simulate  subacute  articular  rheumatism,  though 
it  will  be  observed  that  there  is  absence  of 
blood  changes,  acid  sweats,  and  cardiac  com- 
plication. There  is  swelling,  pain,  and  sore- 
ness of  the  joints,  the  synovial  capsule  and 
bursse  being  especially  involved,  redness  usu- 
ally being  noticed,  and  the  local  symptoms  are 
accompanied  by  moderate  febrile  disturbance.  Periods  of  recupera- 
tion and  exacerbation  may  attend  this  form,  the  acute  symptoms 
subsiding  after  a  few  weeks  or  months,  and  an  approach  toward 
recovery  apparently  following,  to  be  succeeded  by  relapses  or  exac- 
erbations until  the  disease  has  progressed  so  far  as  to  hopelessly 
cripple  the  subject.  Anaemia,  followed  by  slight  hectic,  may  ensue 
upon  the  subsidence  of  the  fever,  the  disease  thus  insidiously 
advancing,  the  patient  never  entirely  recovering  complete  use  of  the 
joints 

Children,  or  women  between  twenty  and  thirty  years  of  age,  who 
have  become  debilitated  by  child-bearing  or  from  excessive  lactation 
may  be  affected,  the  puerperal  period  being  an  apt  time  for  the  acute 
onset.  It  may  also  occur  about  the  menopause. 


ARTHRITIS  DBFORMANS. 


314  CONSTITUTIONAL  DISEASES. 

The  chronic  form  of  progressive  arthritis  deformans  comes  on 
insidiously.  Slight  pain,  tenderness,  and  swelling  may  involve  a 
single  joint  at  first,  apparent  recovery  shortly  ensuing,  perhaps, 
but  recurrences  continuS  to  follow,  one  after  another,  until  perma- 
nent deformity  and  impairment  of  function  become  settled.  Other 
joints  have  become  involved  before  this  time,  sometimes  all  the  large 
ones  being  implicated,  though  often  not  more  than  one  or  two  may 
be  affected.  These  gradually  become  rigid  and  motionless,  and  mus- 
cles atrophy  from  disuse  and  degenerative  changes,  contraction  of 
the  flexors  gradually  drawing  the  thighs  upon  the  abdomen  and  the 
legs  on  the  thighs,  while  the  arms  are  drawn  to  the  sides,  with  the 
forearms  flexed  upon  them  and  the  articulations  locked,  the  patient 
remaining  in  a  recumbent  posture,  unable  to  move  about  or  use  his 
extremities,  except,  possibly,  the  hands,  which  may  have  escaped. 

Diagnosis. — There  is  more  deformity  and  less  severe  pain  when 
the  joints  are  at  rest  than  in  acute  or  chronic  rheumatism,  and 
immobility  progresses  more  rapidly  than  in  either  of  those  affec- 
tions. In  gout,  the  smaller  joints  are  almost  exclusively  affected, 
while  in  this  disease  all  joints  are  equally  liable,  and  the  attacks  are 
not  erratic,  as  in  gout. 

Prognosis. — There  is  little  prospect  of  recovery,  after  the  dis- 
ease has  progressed  far  enough  to  render  the  joints  immobile,  though 
if  treatment  be  begun  early  it  may  be  considerably  modified. 

Treatment. — We  know  so  little  about  remedies  which  influence 
trophic  impulses  that  we  cannot  prescribe  with  any  certainty  on  these 
lines.  However,  we  are  acquainted  with  a  few  remedies  which  seem 
to  exert  an  influence  over  the  nutrition  of  the  joints,  and  it  is  possi- 
ble that  some  if  not  all  of  them  act  through  the  trophic  centers.  It 
is  certain  to  my  mind  that  minute  doses  of  silica  3x,  continued 
through  a  long  period  (a  year  or  more),  exerts  a  decided  influence 
upon  arthritic  conditions  of  the  finger-joints  (Heberden's  nodosities). 
With  this  as  a  pointer,  we  may  make  a  systemtized  study  of  such 
other  agents  as  have  been  known  to  favorably  influence  joint  affec- 
tions of  various  character,  and,  as  the  chronicity  of  these  cases  will 
afford  a  good  opportunity  to  test  them  well,  they  may  be  used  in 
rotation,  giving  each  one  an  extended  trial,  unless,  perchance,  the 
successful  one  should  be  found  early  in  the  day.  We  will  find,  upon 
referring  to  Dynamical  Therapeutics,  that  calcium  floride,  stillingia, 
berberis  aquifolium,  corydalis,  and  several  other  remedies  are  service- 
able in  arresting  the  development  of  nodes,  while  cistus  canadensis, 
kdum  pafustre,  and  puLsatilla  possess  the  reputation  of  influencing 
various  structures  about  the  joints.  A  careful  study  of  these  reme- 
dies in  this  connection  will  afford  some  satisfaction  to  the  investi- 


PSEUDO-RHEUMATIC  AFFECTIONS.  ,.  315 

gating  physician,  and  may  prove  of  lasting  benefit  to  the  patient. 
Massage  is  an  excellent  measure,  and  it  should  be  put  in  practice 
early  and  persisted  in  for  years,  especial  attention  being  paid  to  the 
spinal  column,  joints,  and  muscles.  Cold  compresses  are  serviceable 
to  relieve  pain  in  the  joints,  and  should  be  applied  at  night  espe- 
cially (provided  they  are  comforting  to  the  patient),  that  rest  may  con- 
tribute toward  recovery.  Motion  of  the  joints  should  be  avoided, 
except  passive  motion  during  massage  to  prevent  contraction  of  the 
muscles.  Electricity  affords  little  if  any  benefit.  Depleting  agents, 
such  as  iodide  of  potassium  and  the  salicylates,  should  be  avoided. 

The  diet  should  be  generous,  nourishing,  and  stimulating — the 
very  opposite  to  that  of  rheumatism.  Where  the  digestion  is  good, 
beefsteak,  roast  beef,  mutton,  and  fowl,  fish,  eggs,  and  milk  may  be 
taken  liberally.  Also  fats,  such  as  butter,  cream,  suet  pudding,  olive 
oil,  and  other  oleaginous  articles.  Malt  liquors  are  not  objection- 
able here,  and  porter,  ale,  or  stout  may  be  used,  to  stimulate  diges- 
tion, and  assist  in  nourishing  the  patient. 

Where  the  patient  is  financially  qualified,  the  hot  springs  of  Vir- 
ginia, Arkansas,  or  Banff  may  be  recommended — before  the  disease 
has  advanced  beyond  reasonable  prospects  of  benefit. 

GONOBEHCEAL   RHEUMATISM. 

Definition. — A  septic  synovitis  or  arthritis,  due  to  infection 
from  gonorrhoeal  virus. 

Etiology. — It  is  now  generally  believed  that  ptomaines  gener- 
ated within  and  absorbed  from  the  urethra  give  rise  to  the  mild  or 
non-suppurating  form,  while  the  more  severe  or  suppurating  cases 
arise  from  the  infection  of  the  system  with  pus-organisms.  It  occurs 
more  frequently  in  men  than  in  women,  possibly  because  the  genital 
passage  affords  greater  opportunity  for  the  burrowing  of  the  gonor- 
rhoeal virus.  Relapses  are  common  and  progress  slow,  under  the 
most  favorable  conditions. 

Pathology. — There  is  synovitis,  with  dryness  of  the  synovial 
membrane,  a  crackling  sound  attending  motion  of  the  joint.  In 
severe  cases,  there  is  destruction  of  the  cartilages,  and  permanent 
thickening  of  the  synovial  membrane. 

Symptoms. — The  symptoms  vary  considerably,  the  disease 
sometimes  running  an  acute  and  rapid  course,  and  at  others  assum- 
ing a  chronic  condition,  which  may  last  for  years.  In  some  cases, 
the  symptoms  will  be  limited  to  arthritic  pains,  which  linger  about 
the  joints  for  a  long  time,  there  being  total  absence  of  redness,  swell- 
ing, or  tenderness.  Sometimes  the  joints  are  intensely  painful,  red- 


316  CONSTITUTIONAL  DISEASES. 

dened,  and  swollen,  the  condition  resembling  inflammatory  rheuma- 
tism, but  being  of  more  persistent  and  less  active  character.  In 
another  case,  a  single  joint  may  be  involved,  with  extreme  swelling 
aud  oedema  and  a  probability  of  suppuration,  though  resolution  may 
follow.  Chronic  hydrarthrosis  may  be  one  of  the  conditions,  while 
iu  other  cases  the  burste  of  the  patellae,  olecranon,  and  tendo  Achil- 
lis  may  be  the  parts  principally  affected. 

One  peculiarity  about  the  disease  is  its  tendency  to  involve  artic- 
ulations seldom  affected  by  articular  rheumatism,  such,  for  instance, 
as  the  sterno-clavicular,  sacro-iliac,  iutervertebral,  and  temporo- 
111  axillary.  Fain  is  a  prominent  feature. 

Diagnosis. — The  history  of  the  case  will  be  sufficient  aid  in 
diagnosing  this  disease  from  other  affections  of  the  joints. 

Prognosis. — Not  favorable  to  a  speedy  termination,  though  it 
may  not  shorten  life. 

Treatment. — Herberts  aquifolium,  cistus  canadensis,  and  echinacea 
should  be  tried  persistently.  Cabinet  vapor  baths  afford  some  relief. 
It  is  asserted  that  free  incision  of  badly  affected  joints  with  subse- 
quent irrigation,  affords  the  best  results,  fixation  of  the  joints  to 
prevent  motion  alleviates  much  pain. 

IU.  GOUT. 

Synonyms. — Podagra. 

Definition. — A  disorder  arising  from  disturbances  of  the  assim- 
ilative functions,  characterized  by  attacks  of  acute  inflammation  of 
the  small  joints,  with  the  gradual  deposition  of  urate  of  soda  in  the 
articular  cartilages  and  other  parts  of  the  joints,  with  erratic  consti- 
tutional disturbances. 

Etiology. — Sixty  per  cent  of  all  cases  of  gout  are  hereditary, 
showing  a  constitutional  predisposition.  Inability  to  properly 
assimilate  nitrogenous  material  results  in  an  excess  of  urates  in  the 
system,  these  becoming  deposited  in  the  cartilages  and  other  tissues, 
and  exciting  inflammatory  action. 

Gout  is  a  disease  of  middle  life,  few  suffering  from  it  while  young, 
unless  there  be  an  exceptionally  strong  hereditary  tendency.  The 
gouty  person  is  diseased  from  inability  to  oxidize  nitrogenous  food; 
excess  of  this,  faulty  digestion,  and  sedentery  habits — which  tend  to 
lack  of  oxygen  inthe  system —  being  provoking  factors.  Workers  in 
lead  are  especially  prone  to  gout. 

The  idea  that  all  gouty  persons  are  gourmands  is  a  mistaken  one 
An  individual  may  be  an  apparently  moderate  consumer  of  nitroge- 
nous food  and  yet  be  gouty,  because  he  peculiarly  lacks  the  consti- 


GOUT. 


317 


tutional  ability  to  safely  dispose  of  nitrogenous  food,  either  through 
sedentary  habit,  hereditary  weakness,  or  character  of  vocation.  Not 
all  subjects  of  gout  are  wealthy  and  high-lived.  The  disease  occurs 
among  the  poorer  classes  who  consume  much  malt  liquor,  in  connec- 
tion with  poor  food  and  bad  hygienic  surroundings. 

Pathology. — The  blood  of  gouty  persons  shows  an  excess  of 
uric  acid.  If  five  or  six  drops  of  acetic  acid  be  added  to  ^iii  of  blood- 
serum  from  a  gouty  person  in  a  watch-glass,  and  a  thread  be 
immersed  here  a  few  hours,  it  will  be  found  to  be  incrusted  with 
crystals  of  uric  acid.  The  same  results  occur,  however,  when  serum 
from  the  blood  of  a  leukaemic  or  chlorotic  individual  is  employed. 
In  gout,  the  uric  acid  combines  with  sodium,  and  becomes  deposited 
as  urate  of  soda  in  the  tissues  of  the  articulations,  especially  of  the 
lower  extremities. 


mm 

•.?..ir.v/,  .v-*,-,::..>>-. 


GOUTY  CABTILAGE. 


PAPILLA  OF  GOUTY  KXDSEY. 


These  deposits  may  become  extensive  in  chronic  gout  and  form 
concretions  of  chalky  material  (tophi  or  chalk-stones),  which,  in 
extreme  cases,  may  even  cause  ulcerations  through  the  skin,  and 
appear  externally.  These  concretions,  in  greater  or  less  quantity, 
accumulate  in  the  articular  cartilages  and  cause  necrotic  areas,  the 
part  furthest  from  the  circulation  being  probably  most  affected. 
The  cartilage  in  the  first  joint  of  the  great  toe  is  liable  to  be  involved 
in  the  beginning,  but  the  knees,  ankles,  and  small  joints  of  the  hands 
become  affected  in  succession.  The  cartilages  are  first  involved, 
then  the  nbro-cartilages  and  ligaments  may  be  infiltrated;  the  syn- 
ovial  fluid  may  also  contain  crystals  of  urate  of  soda.  Immobility  of 
the  joints  results  in  long-standing  cases,  as  exostoses,  occurring 
upon  the  margins  of  the  articular  surfaces,  serve  to  lock  those  already 
stiffened  by  concretions  deposited  in  the  fibro-cartilages  and  liga- 
ments. Chronic  gout  is  often  signalized  by  the  appearance  of  yel- 
low nodules  in  the  cartilage  of  the  ear,  at  the  margin  of  the  helix, 
composed  of  gouty  concretions.  These  may  also  accumulate  in  the 
cartilage  of  the  eyelid,  nose,  and  larynx.  The  deposit  is  interstitial, 


318  CONSTITUTIONAL  DISEASES. 

though  it  may  appear  to  be  upon  the  surface  of  the  cartilage,  subse- 
quent coagulation  necrosis  affecting  its  release. 

The  kidneys  and  arteries  suffer  most  severely,  after  the  joints. 
Both  cortical  and  medullary  portions  of  the  kidney  may  be  infiltra- 
ted with  crystals  of  urate  of  soda,  but  the  papillae  are  most  promi- 
nently affected,  striae  of  whitish  deposit  appearing  here,  both  in  the 
intertubular  tissue  and  within  the  tubules.  These  occur  in  intersti- 
tial nephritis,  and  their  presence  cannot  be  considered  pathogno- 
monic  of  gout  unless  there  be  the  articular  disturbance  to  confirm  it. 
Arterio-sclerosis  commonly  occurs  in  chronic  gout,  it  being  asserted 
that  concretions  of  urate  of  soda  are  found  on  the  cardiac  valves,  the 
left  ventricle  being* hypertrophied. 

Symptoms. — Gout  may  be  divided  into  regular  and  irregular 
forms.  In  regular  gout  the  manifestations  occur  about  the  joints, 
principally,  while  in  irregular  gout  there  are  no  arthritic  manifesta- 
tions, internal  organs  being  the  points  of  uratic  deposit.  In  a  few 
acute  cases  there  is  retrocedent  or  suppressed  gout,  the  disappearance 
of  the  arthritis  being  attended  by  serious  disturbance  of  internal 
organs,  such  as  severe  gastro-intestinal  symptoms  (vomiting,  purg- 
ing, abdominal  pain,  and  prostration),  cardiac  manifestations,  such 
as  dyspnoea,  irregular  action  of  the  heart,  or  angina,  and  sometimes 
cerebral  complications,  such  as  delirium  and  coma,  or  apoplexy. 

In  acute  gout  there  may  be  premonitory  symptoms,  such  as 
fugitive  pains  in  the  small  joints  of  the  hands  and  feet,  insomnia,  indi- 
gestion, and  irritability  of  temper,  for  several  days  prior  to  the 
onset  If  the  urine  be  examined  now  it  will  be  found  to  contain 
urates  and  traces  of  albumin  or  sugar.  Asthmatic  attacks  may  also 
occur  during  this  time.  At  length,  between  the  hours  of  one  and 
four  o'clock  A.  M.,  the  subject  is  suddenly  seized  with  an  excruci- 
ating pain  in  the  metatarso-phalangeal  articulation  of  the  great  toe 
of  one  foot  (usually  the  right),  and  this  persists  for  hours,  the  pain 
being  throbbing,  tensive,  or  burning.  The  part  swells  rapidly,  and 
soon  appears  as  though  suppuration  were  impending.  It  is  hot,  tense, 
and  shiny,  and  extremely  sensitive,  the  pain  becoming  agonizing,  as 
though  the  part  were  squeezed  in  a  vise.  The  pain  subsides  in  the 
mo'rning,  though  the  part  remains  swollen  throughout  the  day,  and 
about  the  same  hour  on  the  following  night  there  is  a  recurrence, 
this  state  of  affairs  continuing  for  six  or  eight  days,  the  severity  of 
fche  symptoms  gradually  wearing  away.  During  the  paroxysms  there 
is  considerable  constitutional  disturbance,  the  temperature  rising  to 
102°  or  103°  F.  Desquamation  of  the  skin  follows  the  subsidence  of 
the  swelling.  Within  from  three  months  to  a  year  another  attack 
occurs,  and  now  the  disease  is  liable  to  manifest  a  tendency  to  reach 


GOUT. 


319 


further  out  and  involve  new  territory.  If  one  joint  only  was  affected 
at  first,  the  corresponding  joint  on  the  opposite  foot  may  now  be 
affected  also,  and  another  time  one  or  more  additional  joints  may  be 
involved.  The  recurrences  incline  to  become  more  and  more  fre- 
quent after  each  repetition,  and,  finally,  a  constant  inflammatory  con- 
dition, constituting  chronic  gout,  becomes  established.  During  all 
these  attacks  suppuration  of  a  joint  never  occurs. 

All  goufc  is,  strictly  speaking,  chronic  gout,  but  the  term  is  usually 
applied  to  those  cases  where  the  paroxysms  coalesce  and  the  joints 
have  become  permanently  involved.  Concretions  of  chalky  material 
have  now  formed  around  the  articulations,  and  there  is  such  crip- 
pling as  to  interfere  with  locomotion  and  prehension.  The  joints 

become  noticeably  distorted — enlarged  and 
nodulated — and  immovable,  the  skin  cover- 
ing them  being  congested,  and  the  super- 
ficial veins  dilated.  Tophi  may  perforate 
the  surface  here  later,  and  be  discharged  as 
a  yellowish-white  substance,  or  remain, 
causing  chronic  ulceration. 

The  general  health  now  appreciably 
deteriorates,  the  "gouty  diathesis"  being 
established.  The  skin  is  pale  and  sallow, 
and  the  patient  presents  a  general  appear- 
ance of  invalidism.  There  are  muscular 
cramps,  dyspeptic  symptoms,  cardiac  dis- 
turbances with  occasional  prsecordial  pains, 
irrritability  and  restlessness,  nocturnal 
wakefulness,  tic  douloureux,  urinary  diffi- 
culties with  albuminous  deposits,  gouty 
Daily  heat  and  redness  of  the  nose  is  a  common 


GOUTY  HAND. 


abscesses,  etc. 
symptom. 

Irregular  gout  presents  itself  in  numerous  forms.  Retrocedent 
gout,  which  occurs  in  acute  attacks,  is  included  under  this  term. 
Numerous  individuals  who  belong  to  gouty  families  may  never  man- 
ifest articular  disease,  and  yet  be  subject  to  gouty  affections — uratic 
deposits  in  structures  other  than  those  of  the  joints — and  these  mav 
be  either  acute  or  chronic. 

Nervous  affections  are  common  results  of  irregular  gout.  Head- 
ache, vertigo,  delirium  and  acute  mania  may  result  from  retrocedent 
gout.  More  chronic  conditions  arise  from  gradually  acquired  uratic 
deposits  in  internal  organs.  Epileptic  seizures,  neuritis,  with  neu- 
ralgia, formication  and  numbness,  startings  of  the  limbs,  cramps, 
meningitis,  or  apoplexv  may  be  due  to  the  influence  of  gouty  deposits 


320  CONSTITUTIONAL  DISEASES. 

in  various  portions  of  the  nervous  system,  though  the  apoplexy 
will  usually  be  due  to  involvement  of  the  cerebral  arteries.  Gouty 
implication  of  the  sheath  of  the  sciatic  nerve  may  give  rise  to  an 
obstinate  form  of  sciatica,  which  may  extend  upward  and  involve  the 
spinal  cord. 

Vascular  disorders  may  arise  from  gouty  deposits  in  various  parts 
of  the  circulatory  organs.  There  is  no  special  cardiac  inflammation 
arising  from  gout,  as  in  rheumatism,  but  cardiac  disturbances  from 
gouty  encroachment  are  not  uncommon,  patches  of  deposit  may 
occur  upon  the  pericardium.  Valvular  enlargement  and  obstruction, 
with  subsequent  hypertrophy  and  fatty  degeneration  of  the  heart- 
muscle,  may  arise  from  uratic  deposits  in  their  structure.  Atheroma- 
tous  conditions  of  the  arteries,  or  arterio-capillary  fibrosis  with 
thickening  of  the  muscular  coat  of  the  small  arteries  may  be  set  up. 
Various  unpleasant  symptoms  may  thus  arise,  such  as  erratic  cardiac 
pains,  and  sometimes  angina  pectoris,  palpitation  at  times,  or  slow, 
feeble,  and  irregular  or  intermittent  pulse,  sensations  of  constriction 
about  the  cardiac  region,  with  dyspnoea,  anxiety,  and  sense  of 
impending  dissolution. 

Digestive  disorders  are  common  symptoms  of  irregular  gout. 
There  may  be  erratic  pains  in  the  epigastric  region  with  difficult 
digestion,  or  occasional  attacks  of  gastritis,  with  cramps  and  vomit- 
ing, accompanied,  perhaps,  with  intestinal  colic  and  diarrhoea. 
Hepatic  colic  may  arise,  or  fatty  degeneration  of  the  liver.  Dys- 
phagia  is  not  an  unfrequent  symptom. 

Urinary  difficulties  are  among  the  complications  of  irregular  gout. 
There  may  be  renal  colic  with  calculous  formations,  both  renal  and 
vesical,  with  chronic  vesical  and  urethral  irritation,  and,  sometimes, 
oxaluria. 

Pulmonary  affections  may  be  gouty  in  character,  and  due  to  uratic 
deposits  in  these  organs.  Asthma,  dry  bronchitis,  and  emphysema, 
are  the  common  ailments,  pneumonia  never  arising  as  a  sequela  of 
gout. 

Cutaneous  affections,  arising  in  persons  of  hereditery  tendency  to 
gout,  may  be  very  stubborn  and  intractable,  and  be  ascribed  to  a 
gouty  diathesis.  Eczema,  erythema,  acne,  urticuria,  psoriasis,  pru- 
rigo,  both  local  and  general,  as  well  as  destructive  inflammation  of 
the  iris,  with  loss  of  sight,  may  be  ascribed  to  gouty  influences. 

Diagnosis. — The  only  disease  liable  to  be  mistaken  for  gout  is 
rheumatism.  It  will  be  remembered  that  gout  is  comparatively  rare 
in  this  country,  while  rheumatism  is  quite  common.  The  onset  of 
gout  is  also  peculiar,  only  one  joint  being  involved  in  the  beginning 
(two  at  most),  and  that  usually  the  metatarso-phalangeal  articula- 


GOUT.  321 

tion  of  the  great  toe.  The  time  of  attack — between  midnight  and 
morning — is  also  peculiar.  Subjects  of  gout  are  either  hereditarily 
predisposed,  or  thfey  have  been  addicted  to  high  living  or  malt 
liquors  and  are  accustomed  to  sedentary  habits,  while  subjects  of 
rheumatism  have  been  accustomed  to  hardships  and  exposure. 
Acute  articular  rheumatism  affects  young  persons  and  is  usually 
attended  by  high  fever,  while  gout  hardly  ever  comes  on  before 
thirty-five  and  is  attended  by  mild  febrile  symptoms.  Tophi  never 
form  iu  rheumatism  and  are  common  in  gout,  and  the  microscope 
will  detect  crystals  of  uric  acid  in  the  blood  of  gouty  persons  but 
not  irf  those  with  rheumatism.  The  joint  affection  of  pyaemia  will 
hardly  be  mistaken  for  that  of  gout,  as  the  previous  history  will 
not  permit  of  any  confusion  of  this  kind. 

Prognosis. — Gout  is  not  a  rapidly  fatal  disease,  and  its  sub- 
jects may  live  to  old  age,  though  serious  visceral  complications  are 
liable  to  eventually  terminate  fatally.  Recovery  is  rare,  unless  the 
subject  abandons  a  sedentary  life  and  high  living.  Albuminous 
urine,  with  absence  of  uric  acid  in  the  secretions,  is  ominous,  espe- 
cially if  the  subject  be  cachectic  and  the  joints  are  greatly  crippled. 

Treatment. — A  gouty  subject  should  forever  abandon  an  in-door 
and  sedentary  life,  and  forswear  alcoholic  liquors  and  saccharine 
substances.  An  out-door  life,  with  moderate  exercise,  should  be 
adopted,  and  he  should  eat  to  live,  not  live  to  eat.  A  high  and  dry 
location  is  the  best  place  of  residence,  and  a  climate  permitting  of 
plenty  of  out-door  life  the  year  round  is  preferable,  as  this  conduces 
to  the  inhalation  of  a  generous  amount  of  oxygen.  High,  well  ven- 
tilated rooms,  without  draughts,  should  be  occupied  at  night,  and 
early  retiring  should  be  an  established  custom.  Young  persons 
hereditarily  disposed  to  gout  should  be  encouraged  to  take  plenty 
of  exercise,  though  actual  subjects  of  the  disease  should  avoid  active 
exertion. 

The  diet  is  an  important  consideration.  Sugar  should  be  strictly 
avoided,  and  fruits  containing  much  saccharine  material  should  also 
be  dispensed  with;  for,  though  not  a  nitrogenous  material,  the  pres- 
ence of  sugar  during  the  digestion  of  nitrogenous  food  tends  to  the 
formation  of  uric  acid.  Sweet  wines  and  malt  liquors,  for  similar 
reasons,  come  under  this  objection.  Dilute  old  claret  and  whisky, 
or  dry  sherry  are  the  least  objectionable,  though  total  abstinence  is 
best,  unless  there  is  some  urgent  need  for  alcohol — something  not 
liable  to  often  occur.  Much  starchy  food  is  also  objectionable,  as 
the  starch  is  converted  into  sugar  during  digestion. 

The  diet  of  a  gouty  person  should  consist  principally  of  fresh 
green  vegetables,  with  a  few  fruits — which  do  not  contain  much 


322  CONSTITUTIONAL  DISEASES. 

sugar — used  sparingly.  As  this  entails  a  certain  objectionable  bulki- 
ness  to  the  amount  of  food  required,  however,  a  small  portion  of 
lean  beef  or  mutton  may  be  allowed  each  day,  though  this  should 
never  be  cooked  but  once — never  warmed  over.  Pickled  meats 
should  never  be  used,  as  they  are  especially  objectionable,  and  so  also 
are  all  forms  of  pickled  fish.  Certain  kinds  of  fresh  fish  are  allow- 
able, such  as  those  which  are  tender  when  boiled  or  broiled  (the 
form  to  be  taken  in ),  but  those  of  firm  flesh  and  containing  consid- 
erable fat,  like  the  salmon,  mackerel,  halibut,  and  codfish  should  be 
avoided.  The  best  fisli  for  the  gouty  are  the  bluefish,  whitefish, 
bass,  and  shad,  which  may  be  taken  occasionally,  as  a  change  of  food. 
Oysters  and  clams  are  allowable,  but  shrimps,  lobsters,  and  crabs 
should  be  prohibited,  their  use  on  salads  being  especially  pernicious. 
Eggs  are  generally  prohibited.  Milk  disagrees  with  many,  and  is 
believed  to  be  injurious  to  old  persons  afflicted  with  gout.  Veal, 
pork,  bacon,  ham,  and  game  are  not  allowable.  A  few  vegetables 
are  prohibited  on  account  of  the  fact  that  they  contain  oxalic  acid, 
which  produces  oxaluria.  These  are  sorrel,  radishes,  asparagus, 
and  rhubarb.  Some  debar  tomatoes  and  spinach,  on  the  same 
grounds.  Beets,  being  sugar-producing  vegetables,  are  forbidden, 
and  also  those  which  possess  the  objection  that  they  occasion  flatu- 
lence, such  as  cabbage,  green  corn,  matured  peas,  beans,  onions, 
and  corn.  Oil  should  be  omitted  from  salads,  as  all  fats  embarrass 
the  digestion  of  nitrogenous  food.  All  food  cooked  in  fat  must  be 
avoided,  though  butter  may  be  allowed  sparingly.  Farinaceous  food, 
stale  bread,  rice,  sago,  tapioca,  oatmeal,  and  cracked  wheat  may  be 
allowed,  but  pastry,  hot  rolls,  warm  bread,  hominy,  and  griddle  cakes 
should  be  avoided.  All  preserves  and  confectionery  are  to  be  for- 
bidden; also  fruits  which  contain  a  large  amount  of  sugar,  as  grapes, 
figs,  banannas,  and  prunes.  Strawberries  are  also  objectionable, 
because  they  contain  much  acid.  Fruits,  served  for  the  gouty, 
should  be  taken  without  the  addition  of  sugar.  Apples  and  pears, 
when  well-ripened  (fresh,  baked,  or  stewed),  may  be  allowed. 
Oranges  and  lemons  may  be  partaken  of  sparingly.  Nuts,  pickles, 
vinegar,  spices,  strong  condiments,  salted  foods,  truffles,  and  mush- 
rooms are  to  be  prohibited. 

Fluids  are  essential,  and  water  may  be  taken  freely,  as  plenty  of 
diluent  tends  to  flush  the  tissues  and  wash  away  gouty  material. 
All  fluids,  however,  should  be  taken  between  meals.  Weak  tea  and 
coffee  may  be  taken  without  sugar,  though  they  are  better  omitted 
entirely,  not  because  they  aggavate  gouty  conditions,  but  because 
there  are  other  objections.  Alcoholic  drinks  have  already  been  men- 
tioned. Saline  and  mineral  waters  are  excellent  for  gouty  subjects, 


LITELEMIA.  323 

and  two  or  three  courses  at  certain  mineral  springs  every  year  are 
to  be  com  mended.  Some  of  the  leading  waters  of  this  country  are 
at  the  springs  of  Saratoga,  New  York;  St.  Clair,  in  Michigan;  St. 
Catherine,  in  Ontario;  the  hot  springs  of  Arkansas,  Virginia,  and 
California  (Paso  Robles),  and  various  others.  The  Carlsbad  Springs 
in  Bohemia  are  a  favorite  resort  for  Europeans,  and  many  Americans. 

The  medical  treatment  of  gout  consists  in  the  use  of  cdchicum  and 
guaiacuni  during  acute  attacks,  and  lithium  as  an  alternate,  or  remedy 
for  the  intermediate  periods.  Five  grains  of  the  citrate  of  lithium 
may  be  taken  at  a  dose,  three  or  four  times  daily,  dissolved  in  a 
glassful  of  potash  water.  During  an  acute  attack,  the  affected  foot 
should  be  elevated  and  from  twenty  to  thirty  drops  of  wine  of  col- 
chicnm  administered  every  three  hours,  until  its  purgative  action 
becomes  manifest,  when  the  dose  should  be  diminished  to  one-fourth 
the  size,  or  less.  This  may  be  alternated  or  combined  with  the  cit- 
rate of  lithium,  as  already  directed.  A  flannel  or  cotton  batting 
wrapping  should  be  kept  around  the  affected  joint,  and  this  may  be 
moistened  with  chloroform  liniment,  to  be  repeated,  if  relief  attends 
its  action.  Sometimes  a  hypodermic  injection  of  morphine,  near  the 
joint,  is  useful  to  relieve  the  severe  suffering.  Chronic  gout  will 
require  the  judicious  selection  of  proper  tonics,  the  influence  of  sil- 
ica upon  the  nutrition  of  cartilage  being  remembered. 

Dr.  Lional  S.  Beale  believes  that  other  alkalis  than  lithia  are 
sometimes  more  efficacious.  He  believes  in  their  rotation,  as  the 
single  agent  seems  to  finally  lose  much  of  its  effect  when  continued 
for  a  protracted  period.  He  thus  employs  various  carbonates,  such 
as  carbonate  of  lithia,  potash,  soda,  and  ammonia.  Vapor  baths 
will  assist  in  the  treatment  of  chronic  cases,  by  promoting  activity 
of  the  skin. 

During  acute  gout  considerable  benefit  may  be  derived  from  jab- 
orandi  and  other  properly  selected  sedatives,  administered  often,  in 
small  doses,  though  as  much  benefit  must  not  be  expected  as  in 
rheumatism. 

IV.  LITHJEMIA. 

Definition. — A  condition  in  which  there  is  an  excess  of  uric 
acid  in  the  blood,  characterized  by  disturbances  in  the  retrograde 
changes  of  the  body,  with  excess  of  lithic  acid  in  the  urine,  the  renal 
secretion  being  increased. 

Etiology. — This  disease  is  a  functional  one  (there  being  no 
uratic  deposits  in  the  system),  the  tendency  to  such  a  condition 
depending  largely  upon  inheritance.  It  afflicts  those  who  have  never 
indulged  in  excessive  eating  or  drinking,  a  primary  weakness  of  the 


324  CONSTITUTIONAL  DISEASES. 

digestive  and  assimilative  powers  seeming  to  be  at  the  fonndation 
of  the  trouble.  In  other  cases,  excesses  in  eating  or  drinking,  or 
protracted  sedentary  habits  may  be  reasons  for  its  acquirement. 
Indulgences  in  the  consumption  of  meat,  stimulants,  or  narcotics, 
sexual  excesses,  or  prolonged  mental  or  nervous  strain  may  either 
develop  such  a  state,  or  aggravate  and  render  prominent  latent 
lithaemic  tendencies  already  inherited.  Lack  of  power  to  digest 
nitrogenous  material  results  in  the  formation  of  uric  acid  in  the 
blood.  The  condition  is  sometimes  associated  with  rectal  disease, 
especially  papillae  and  pockets,  and  it  seems  as  though  this  condi- 
tion might  be  a  frequent  causal  factor. 

Anything  that  interferes  wito.  a  free  supply  of  arterial  blood  to 
the  superficial  capillaries  will  naturally  tend  to  bring  about  lithse- 
mia.  Obstruction  may  be  one  cause,  and  perverted  or  inadequate 
peristaltic  action  of  the  alimentary  canal  another.  Splenic  or 
hepatic  engorgement  tends  to  interfere  with  the  free  flow  of  blood 
through  the  casliac  axis,  and  therefore  interferes  with  a  vigorous 
abdominal  circulation.  Malarial  cachexia  commonly  predisposes  to 
this  condition,  and  lithaemia  may  arise  as  a  result.  The  second  con- 
dition, torpid  peristaltic  action,  may  arise  from  chronic  constipation, 
the  frequent  cause  of  this  condition  being  rectal  disease,  with 
sphincteral  spasm.  That  oxygen  in  the  intestinal  capillaries  aids  in 
the  elimination  of  uric  acid  in  the  blood  has  been  proven  experi- 
mentally, by  the  rectal  use  of  oxygen  gas  in  lithaemia. 

Pathology. — Arterial  changes  are  the  most  common  and  seri- 
ous pathological  changes  which  occur.  While  there  is  no  evidence 
of  uratic  deposits  in  the  tissues,  arterio-sclerosis  from  fibroid  degen- 
eration frequently  occurs.  Many  disturbances  similar  to  those  aris- 
ing from  irregular  gout  also  arise,  such  as  gastro-intestinal  irritation, 
asthma,  cardiac  disturbance,  neuralgia,  and  headache. 

Symptoms. — Acute  and  chronic  indigestion  are  the  leading  fea- 
tures of  this  disease.  Acid  eructations,  flatulency,  and  constipation 
are  usually  present,  though  the  bowels  may  move  regularly  or  there 
may  be  diarrhoea  alternated  with  constipation.  Though  there  may 
be  no  coating  on  the  tongue,  the  breath,  as  well  as  the  exhalations 
and  perspiration,  is  usually  offensive. 

The  skin  and  its  appendages  manifest  evidences  of  perverted 
nutrition.  The  skin  is  dry  and  scaly,  and  there  are  often  cutaneous 
eruptions,  eczematous  in  character.  The  hair  and  nails  are  dry  and 
brittle.  Temporary  palpitation  of  the  heart  is  a  common  symptom, 
this  being  functional  in  character,  usually,  and  is  often  aggravated 
or  brought  on  by  eating.  Slight  jaundice  may  be  present,  and  care- 
ful palpation  may  detect  hepatic  congestion.  Nervous  symptoms, 


LITH^MIA.  326 

such  as  headache,  giddiness,  insomnia,  with  oppression  of  breathing 
at  night,  requiring  an  upright  position,  melancholy  and  despondency 
with  erratic  irritability  and  anxiety,  are  prominent  features,  due 
rather  to  digestive  disturbance  than  to  the  presence  of  lithic  acid. 
The  urine  is  usually  high-colored,  and  deposits  a  sediment  upon 
standing  until  cool.  This  may  consist  of  uric  acid,  urea,  phosphates, 
and  oxalate  of  lime.  Examination  of  the  heart  may  detect  arte- 
rial tension,  and  such  a  condition  may  persist  years  without  apparent 
serious  results,  though  finally  gout,  arterio-sclerosis,  or  contracted 
kidney  will  become  fully  developed. 

Diagnosis. — The  persistent  and  distressing  gastric  disturbance 
following  eating,  and  the  almost  constant  presence  of  an  excess  of 
uric  acid  and  phosphates  in  the  urine,  will  distinguish  this  condition. 

Prognosis. — "Where  treatment  is  begun  early,  and  intelligently 
pursued,  there  is  little  doubt  of  success,  provided  the  patient  will 
assist  by  adhering  to  a  proper  diet. 

Treatment. — Attention  should  be  paid  to  the  habits  of  the 
patient  as  regards  exercise,  diet,  and  the  general  condition  of  the 
alimentary  canal.  Careful  examination  should  be  made  to  deter- 
mine, if  possible,  a  local  cause  for  the  flatulency  and  indigestion. 
Hypertrophy  of  the  spleen  will  demand  the  use  of  carduus  marianus, 
poiymnia,  ceanothus,  or,  if  there  be  pronounced  malarial  complication, 
grinddia  squarrosa.  Hepatic  congestion  will  suggest  chelidonium,  nux 
vomica,  or  nitro-hydrochloric  acid.  To  relieve  the  excess  of  uric  acid 
in  the  blood,  the  citrate  or  carbonate  of  lithia  should  be  taken  in  three- 
or  four-grain  doses,  dissolved  in  water,  three  times  daily.  Pipera- 
zin  is  another  remedy  for  this  condition,  and  a  very  reliable  one. 
Three  or  four  grains  may  be  taken  at  a  dose,  four  times  daily. 

Cabinet  vapor  baths,  aided  by  the  tonic  faradic  treatment,  exert  a 
highly  beneficial  influence  here,  promoting  cutaneous  secretion  and 
invigorating  the  organs  of  digestion  and  circulation,  as  well  as 
relieving  insomnia  and  painful  conditions.  The  patient  should 
remain  in  the  bath  from  fifteen  to  thirty  minutes,  and  it  should  be 
repeated  two  or  three  times  each  week.  It  will  assist  other  meas- 
ures very  much,  and  should  not  be  omitted. 

Careful  inspection  of  the  condition  of  the  rectum  should  be  made, 
and  any  evidence  of  disease  here  be  corrected.  Rectal  pockets  and 
papillae  should  be  incised,  and  hemorrhoids,  ulcers,  and  other  dis- 
ease properly  treated,  the  sphincter  ani,  meantime,  being  well 
stretched. 

The  diet  should  consist  largely  of  milk  and  vegetable  food,  butch- 
ers' meat  being  an  aggravating  cause  of  the  difficulty.  Fruits  are 
not  objectionable,  and  may  be  partaken  of  freely.  Only  once  a  day 


326  CONSTITUTIONAL  DISEASES. 

should  any  form  of  meat  be  included  in  the  dietary,  and  this  should 
then  be  used  sparingly.  Quantity  should  also  be  considered,  and 
the  amount  of  food  consumed  limited  to  the  actual  needs  of  the  body. 

In  order  to  promote  free  peristaltic  action  and  a  vigorous  abdom- 
inal circulation,  a  copious  clyster  of  strong  salt  water  should  be  used 
every  morning,  soon  after  breakfast,  and  repeated,  if  a  free  evacua- 
tion does  not  follow  the  first  injection;  and  upon  retiring  at  night 
and  rising  in  the  morning,  the  whole  abdominal  surface,  especially 
that  over  the  epigastric  region,  should  be  vigorously  slapped  with 
the  open  hands.  This  may  seem  a  hardship  at  first,  but  it  will 
finally  become  a  source  of  pleasure. 

Mineral  waters  are  beneficial,  and  plenty  of  pure  water  is  always 
proper.  Alcoholic  beverages  are  not  admissible,  and  tea  and  coffee 
should  be  substituted  by  a  single  cup  of  weak  cocoa  at  breakfast, 
milk  or  water  being  taken  at  other  times. 

V.  DIABETES  MELLITTTS. 

Synonyms. — Glycosuria;  Glucosuria;  Glyeoheemia;  Mellituria. 

Definition. — A  constitutional  disorder  arising  from  malassimi- 
lation,  characterized  by  the  presence  of  sugar  in  the  urine. 

Etiology. — It  has  been  discovered  that  an  area  exists  in  the 
medulla  oblongata  (on  the  floor  of  the  fourth  ventricle)  which  pre- 
sides over  the  glycogenic  functions,  and  that  if  this  part  be  irritated, 
either  experimentally  or  accidentally,  sugar  soon  afterward  appears 
in  the  urine.  Concussion  of  the  brain,  cerebral  hemorrhage,  softeu- 
ing  of  the  brain,  or  other  cerebral  disease,  such  as  cirrhosis  or 
pressure  from  tumor,  may  give  rise  to  glycosuria.  Any  cause  of  irri- 
tation of  the  glycogenic  center,  even  mental  stress,  such  as  severe 
mental  strain,  grief,  or  sudden  shock  from  fright  or  surprise,  may 
result  in  this  disease.  Alcoholism,  pregnancy,  indigestion,  and  the 
immoderate  use  of  sugar  and  new  wine  have  been  ascribed  as  causes. 

Pathology. — Sugar  is  found  in  the  blood,  and  in  the  secretions 
and  excretions  of  all  organs,  though  most  abundantly  in  the  urine. 
The  amount  may  equal  nine  or  ten  parts  in  a  thousand  of  the  blood, 
and  here  are  also  found  glycogen,  acetone,  and  kreatin,  the  propor- 
tion of  fat  also  being  greater  than  normal. 

Nearly  all  the  vital  organs  manifest  evidences  of  degenerative 
changt.  as  the  disease  progresses.  The  liver  is  hypersemic,  with 
.ireas  of  fatty  degeneration,  and  the  lungs  show  points  of  catarrhal 
pneumonia  with  gangrenous  tendencies,  tuberculous  deposits,  or 
patches  of  pleuritic  inflammation.  The  spleen  is  enlarged,  congested, 
anil  hardened.  The  kidneys  are  hypersemic,  and  bear  evidence  of 


DIABETES  MELLITUS.  327 

parenchymatous  inflammation.  The  heart  is  pale,  soft,  and  flabby, 
and  the  muscles  generally  are  pale  and  dry.  The  brain  is  variously 
altered,  sometimes  being  cirrhotic,  at  others  softened,  and  tumors 
may  be  present  about  the  fourth  ventricle,  suggesting  a  probable 
cause  of  the  disease.  Wandering  parasites  (cysticerci)  may  burrow 
in  the  region  of  the  diabetic  area  and  cause  the  irritation  essential 
to  the  disease.  The  pancreas  is  often  notably  altered,  atrophy  and 
fibroid  degeneration  being  the  condition.  Emaciation  is  a  marked 
feature  in  autopsies,  and  the  skin  is  usually  the  seat  of  various 
degenerative  changes,  such  as  boils,  carbuncles,  and  gangrene. 

Symptoms. — Two  forms  occur,  the  acute  and  the  chronic. 
The  acute  form  commonly  attacks  young  persons  or  those  below 
middle  age,  while  chronic  diabetes  is  most  usually  observed  in 
those  of  advanced  life.  Acute  cases  are  rapid  in  their  course,  termi- 
nating fatally  within  a  few  weeks,  while  chronic  diabetes  may  linger 
for  years. 

In  any  event,  the  onset  is  usually  insidious.  The  subject  may  be 
impressed  that  he  is  losing  strength  and  flesh,  that  there  is 
unnatural  thirst,  and  that  he  is  obliged  to  rise  frequently  to  urinate, 
during  the  night.  Sexual  desire  soon  becomes  abolished,  and  intol- 
erable itching  of  the  genitals  or  other  parts,  with  unnatural  dryness 
of  the  skin  and  mucous  membranes,  is  present.  Arrest  of  the  menses 
occurs  in  women,  often  with  troublesome  pruritus  pudendi,  as  well 
as  itching  of  the  cutaneous  surface. 

Thirst  is  a  prominent  and  distressing  symptom,  and  a  large 
amount  of  water  is  consumed,  the  greatest  quantity  being  demanded 
an  hour  or  two  after  meals.  Digestion  is  often  good  in  chronic 
cases,  and  the  appetite  may  be  ravenous. 

The  tongue  is  dry,  red,  and  glazed,  or,  in  some  chronic  cases, 
covered  with  a  dry  brown  coating ;  the  throat  is  dry,  and  the  saliva 
scanty  and  viscid,  or  absent.  The  gums  are  pale  and  retracted,  and 
bleed  easily,  and  the  teeth  soon  become  carious.  The  breath  and 
exhalations  from  the  body  generally  are  marked  by  a  sweetish  odor. 
In  acute  cases  there  may  be  nausea  and  vomiting,  with  dyspeptic 
symptoms,  and  intense  headache  followed  by  delirium  and  coma  may 
occur. 

The  special  senses  may  be  involved,  especially  that  of  sight,  soft 
cataract  or  amblyopia  sometimes  developing.  The  temperature, 
pulse-rate,  and  respiration  are  usually  below  normal.  Mental  symp- 
toms are  prominent  in  most  cases  of  diabetes.  The  patient  is  irri- 
table, peevish,  restless,  and  melancholic,  with  periods  of  dullness 
and  apathy. 

THE  URINE. — The  urine  is  a  subject  of  considerable  importance 


328  CONSTITUTIONAL  DISEASES. 

in  this  disease,  as  it  is  the  principal  element  to  be  considered  in 
diagnosis.  Occasionally  there  is  not  marked  increase  in  quantity, 
but  usually  the  amount  voided  is  enormously  large,  amounting,  in 
mild  o  ises,  to  from  six  or  eight  pints,  to  as  high  as  fifty  in  extreme 
cases,  within  twenty-four  hours.  The  specific  gravity  is  high,  rang- 
ing from  1.026  to  1.045.  The  urine  is  pale  and  clear,  almost  as  lim- 
pid as  water,  and  possesses  a  sweetish  odor  and  taste,  and  an  acid 
reaction.  Tests  for  sugar  detect  a  varying  quantity  (from  one  to 
ten  per  cent)  of  sugar  present.  Ten  or  twenty  ounces,  and  even  as 
much  as  one  or  two  pounds,  may  be  excreted  in  twenty-four  hours. 

Various  tests,  to  determine  the  presence  of  sugar  in  suspected 
urine,  have  been  recommended.  A  few  of  the  most  important  ones 
are  appended: 

Trommer's  Test. — Add  a  few  drops  of  a  dilute  solution  of  sulphate 
of  copper  to  a  drachm  of  urine  in  a  test-tube,  and  then  an  equal 
balk  of  liquor  potassse.  Boil,  and  if  sugar  be  present,  a  yellow  or 
orange  red  precipitate  occurs. 

Filing's  Test. — Add  a  drachm  of  Fehling's  solution  to  a  test-tube 
and  boil.  If  the  solution  remain  clear,  add  a  few  drops  of  the 
suspected  urine,  and  boil  again.  If  there  be  sugar  present,  the  yel- 
low suboxide  of  copper  is  precipitated. 

Fermentation  Test — Add  a  particle  of  yeast  to  a  test-tube  full  of 
urine,  and  invert  the  tube  so  it  will  stand  in  the  same  liquid,  in  an 
open  vessel.  If  there  be  sugar  present,  fermentation  will  go  on  with 
the  formation  of  carbon  dioxide,  which  accumulates  in  the  upper 
portion  of  the  tube  and  gradually  expels  the  urine. 

Bismuth  Test. — To  half  a  drachm  of  the  suspected  urine  add  an 
equal  bulk  of  solution  of  potassa  and  a  pinch  of  subnitrate  of  bis- 
muth, and  boil  for  one  or  two  minutes.  If  sugar  be  present,  black, 
metallic  bismuth  deposits. 

COMPLICATIONS. — Various  complications  arise  as  results  of  the 
continued  presence  of  the  saccharine  material  in  the  blood: 

Cutaneous  affections,  such  as  eczema,  boils,  and  carbuncles,  and 
sometimes  gangrene,  are  apt  to  arise.  Pruritus  may  attend  any  of 
these,  or  arise  independently.  The  frequent  calls  to  urinate  and  the 
local  irritation  caused  by  the  affected  urine  give  rise  to  severe  ery- 
thematous  inflammation  about  the  genitals  in  some  cases,  especially 
in  women,  and  balanitis  is  not  uncommon  in  men.  In  other  cases 
there  may  be  only  troublesome  itching. 

The  urinary  tract  generally,  may  be  involved.  Cystitis  or  nephri- 
tis may  be  present,  and  albuminuria  may  develop  in  connection  with 
arterio-sclerosis. 

Pulmonary  complications  are  frequent,  pneumonia  or  pulmonary 


DIABETES  MELLITUS.  329 

gangrene  arising,  the  pleura  sometimes  participating.  Tuberculous 
complication  often  occurs  in  the  bronchi  or  lung  parenchyma,  in 
which  the  tubercle  bacilli  are  present,  demonstrating  true  tuber- 
culosis. 

A  wide  range  of  nervous  symptoms  attend  this  disease.  Diabetic 
coma  is  a  frequent  complication  among  young  subjects.  It  may 
sometimes  be  the  first  symptom  to  be  noticed,  and  it  terminates 
many  cases  suddenly.  Headache,  delirium,  and  dyspnoea,  with  sub- 
sequent cyanosis,  rapidly  failing  pulse,  exhaustion-,  and  coma,  with 
death  in  four  or  five  days,  are  the  usual  symptoms.  Sometimes  sud- 
den exhaustion  and  coma  come  on  after  severe  exertion,  the  patient 
succumbing  in  a  few  hours.  In  other  cases,  the  patient  may  be  sud- 
denly attacked  with  severe  headache  and  intoxication,  without  pre- 
vious dyspnoea  or  exertion,  and  rapidly  sink  into  unconsciousness 
and  fatal  stupor. 

Disturbances  of  motion  and  sensation  arise  in  various  instances. 
Periplieral  neuritis,  characterized  by  numbness,  tingling,  or  neuralgic 
pains  darting  through  the  lower  extremities,  sometimes  occurs, 
attended  by  loss  of  muscular  power,  with  absence  of  knee-jerk,  power 
in  the  extension  of  the  feet,  and  even  loss  of  strength  in  the  arms 
and  legs.  k 

Diagnosis. — The  loss  of  flesh  and  strength,  with  thirst  and 
marked  increase  in  the  amount  of  urine  voided,  will  suggest  the  dis- 
ease, and  urinary  analysis  will  settle  the  question. 

Prognosis. — Mild  cases  of  glycosuria  may  recover  under  treat- 
ment, and  chronic  cases  may  be  modified,  for  years,  but  there  can  be 
little  hope  held  out  in  acute  attacks. 

Treatment. — Though  modification  of  the  diet  cannot  be 
expected  to  exert  a  curative  influence,  it  doubtless  lessens  the  sever- 
ity of  the  disease,  and  thus  aids  in  its  successful  management.  Mbn- 
tal  strain  is  aggravating  in  its  influence,  and  the  patient  should 
be  removed  from  all  causes  of -worry  or  mental  effort,  and  be  allowed 
to  live  a  quiet  and  even  life,  in  a  mild  climate,  where  winter  and  sum- 
mer nearly  meet.  As  the  capillary  circulation  is  usually  poor,  the 
underclothing  should  be  of  flannel  or  silk,  and  the  skin  should  be 
kept  moist  and  open  by  a  daily  cabinet  vapor  bath  (unless  the  patient 
be  too  much  exhausted)  and  by  daily  falty  inunction  with  massage. 

The  diet  should  consist  of  easily  digested  meats,  fish,  poultry, 
and  game  without  reserve,  except  liver,  crabs,  lobsters,  and  oysters; 
liquids,  except  those  containing  sugar,  such  as  beer,  sweet  wines,  and 
sweet  aerated  drinks;  and  vegetables,  except  potatoes,  turnips,  para- 
nips,  squashes,  vegetable  marrow,  asparagus,  corn,  beets,  and  arti- 
chokes. Fruits  should  be  prohibited,  except  lemons,  oranges,  and 


330  CONSTITUTIONAL  DISEASES. 

currants.  The  bread  should  be  restricted  to  gluten  and  bran  bread, 
and  almond  and  cocoanut  biscuits.  All  wheat  and  rye  bread  should 
be  avoided,  while  such  farinaceous  foods  as  rice,  hominy,  tapioca, 
semolina,  sago,  arrowroot,  and  vermicella  are  not  permissible.  It  is 
said  that  gluten  flour  obtained  in  this  country  contains  too  great  a 
proportion  of  starch — that  that  from  Paris  and  London  contains  a 
much  smaller  amount  of  this  element,  and  is  to  be  preferred.  As 
the  breads  especially  prepared  for  diabetics  are  all  unpalatable,  and 
soon  become  distasteful  to  the  patient,  it  may  be  better  to  allow  a 
restricted  quantity  (a  few  ounces)  of  ordinary  bread  daily,  though 
this  should  then  be  well  toasted,  to  disorganize  the  sugar  and 
dextrin. 

The  milk  diet  advised  by  Donkin  and  at  one  time  popular  in  dia- 
betes has  failed  to  prove  generally  satisfactory,  though  some  cases 
improve  on  it. 

As  a  substitute  for  sugar,  saccharin  and  glycerine  may  be 
employed. 

The  medical  treatment  of  diabetes  is  not  yet  very  successful, 
though  we  have  improved  upon  older  methods.  Syzygium,  when  a 
recent  preparation  can  be  obtained,  removes  the  sugar  from  the  urine 
in  many  instances.  Unfortunately,  there  is  no  guarantee  of  the  char- 
acter of  an  article  obtained,  and  it  has  often  been  so  long  in  the  mar- 
ket as  to  have  lost  its  therapeutic  value.  Three  or  four  grains  of 
the  powdered  seeds,  in  capsules,  constitute  a  dose,  to  be  repeated 
three  or  four  times  daily.  In  the  use  of  any  remedy  in  this  disease, 
perseverence  is  a  necessary  virtue.  Nitrate  of  uranium  controls  pro- 
fuse urinary  discharge,  and  thus  modifies  many  unpleasant  features. 
Where  there  is  much  pain  and  restlessness,  the  following  capsule 
may  answer  a  good  purpose  :  #  Phenacetin  gr.  ii,  nitrate  of  uranium 
3i  trit.,  gr.  iii.  M.  This  may  be  given  every  two  or  three  hours. 

Rhus  aromatica  and  lycopus  virginicus  have  both,  according  to 
written  reports,  accomplished  cures  -of  diabetes.  Whether  these 
were  cases  of  genuine  glycosuria  or  merely  diabetes  iusipidus,  where 
agents  controlling  an  excessive  hydruria  are  expected  to  succeed, 
still  remains  to  be  satisfactorily  proven.  There  is  no  reason  either 
of  these  remedies  should  fail.  Lycopus  is  invigorating  to  the  diges- 
tion, promotes  normal  activity  of  the  heart  and  arteries,  and  allays 
gastric  and  enteric  I  irritability,  thus  seeming  well  adapted  to  some 
of  the  conditions  of  this  disease,  while  it  controls  relaxation  of  the 
renal  capillaries,  thus  being  commendable  for  trial,  at  least.  It  has 
the  reputation  of  having  cured  many  cases  of  diabetes  mellitus. 
It  should  be  given  in  ten-drop  doses  of  the  specific  medicine,  every 
three  or  four  hours.  Professor  I.  J.  M.  Goss,  in  his  Practice  of 


DIABETES  INSIPIDUS.  331 

Medicine,  describes  the  case  of  an  old  man  (74  or  75  years  of  age) 
whose  urine  showed  a  specific  gravity  of  1.045  and  upon  evapora- 
tion yielded  a  considerable  quantity  of  what  was  apparently  saccha- 
rine material,  in  which  rhus  aromatica  effected  a  complete  cure 
within  three  months.  Lycopus  and  uranium  were  used  the  first 
month  of  treatment,  with  only  the  result  of  lessening  the  volume  of 
water  passed.  The  following  month  he  was  put  upon  30-drop  doses 
of  rhus  aromatica  three  times  daily,  and,  at  its  expiration,  there  was 
a  noticeable  diminution  in  the  amount  of  urine  voided,  and  its 
specific  gravity  was  1.032.  The  same  treatment  was  continued  for 
another  month,  the  patient  meantime  gaming  flesh  and  strength 
rapidly,  and,  after  the  third  month  he  reported  himself  well,  and  so* 
continued.  It  is  to  be  regretted  that  a  chemical  analysis  was  not 
made  at  the  beginning  and  ending  of  treatment  in  this  instance, 
that  more  positive  statements  might  have  been  made. 

Opium  possesses  the  reputation  of  limiting  the  progress  of  the 
disease,  codeia  being  the  form  generally  preferred,  as  it  is  less 
constipating.  The  drug  may  be  begun  in  small  doses — half  a  grain 
three  times  daily — anil  gradually  increased,  as  the  patient  becomes 
tolerant,  to  six  or  eight  grains  in  twenty-four  hours. 

Dr.  J.  Q-.  Pierce  has  employed  bromide  of  potassium  in  the  treat- 
ment of  cases  where  the  disease  was  brought  on  by  injury,  such  as 
falls  resulting  in  concussion,  with  promising  results.  In  one  of 
his  cases,  that  of  a  young  girl,  it  was  brought  on  by  extreme  grief  at 
the  death  of  her  mother,  and  here  a  complete  cure  resulted. 

During  coma  little  can  be  done,  though  inhalations  of  oxygen 
and  intravenous  injections  of  a  three-per-cent  solution  of  bicarbon- 
ate of  sodium  have  been  recommended  and  employed,  but  not  with 
very  satisfactory  results. 

VI.  DIABETES  INSIPIDUS. 

Synonyms. — Polyuria;  Polydipsia. 

Definition. — A  constitutional  disease,  characterized  by  extreme 
thirst  and  the  excretion  of  a  large  amount  of  colorless  urine  of  low 
specific  gravity,  containing  neither  sugar  nor  albumin. 

Etiology. — The  etiology  of  this  disease  is  obscure,  but  many 
circumstances  point  to  a  nervous  origin.  For  instance,  it  is  apt  to 
follow  blows  on  the  head,  or  injuries  to  th'e  occipital  region  of  the 
skull.  Bernard  discovered  a  spot  in  the  floor  of  the  fourth  ventricle 
in  animals,  the  puncture  of  which  was  followed  by  this  condition. 
It  occurs  most  commonly  in  young  persons,  and  heredity  seems  to 
exert  an  influence.  Excesses  in  drinking,  both  of  ice-water  and 


332  CONSTITUTIONAL  DISEASES. 

alcoholic  liquor,  have  been  followed  by  it.  It  sometimes  appears  dur- 
ing the  course  of  such  visceral  lesions  as  hepatic  cirrhosis  and 
abdominal  tumors,  some  impression  being  made  here  upon  the  renal 
nerves,  in  all  probability.  Cerebral  tumors  have  caused  it,  and  sun- 
stroke, apoplexy,  and  other  brain  lesions  have  been  followed  by  it. 
Males  are  more  subject  to  it  than  females,  probably  because  they 
are  more  liable  to  causes  of  violence  which  predispose  to  it. 

Pathology. — Various  degenerative  changes  have  been  found  in 
the  central  and  sympathetic  ganglia.  Anatomical  lesions  of  the 
kidneys  and  bladder  sometimes  occur,  the  bladder  being  hypertro- 
phied,  and  the  pelves  of  the  kidneys,  and  ureters  dilated.  Chronic 
pulmonary  complications  may  arise,  with  fatal  termination  by 
tuberculosis. 

Symptoms. — The  principal  symptoms  in  the  beginning  are 
inordinate  flow  of  urine,  and  thirst.  The  urine  is  limpid,  colorless, 
of  low  specific  gravity,  and  shows  no  reaction  with  agents  employed 
for  testing  for  sugar.  The  disease  may  come  on  insidiously  or  sud- 
denly, the  amount  of  urine  voided  finally  reaching  from  thirty  to 
sixty  pints  per  day.  The  specific  gravity  varies  from  1.003  to  1.008. 
The  reaction  is  faintly  acid,  there  is  a  greenish,  opalescent  color,  and 
uric  acid,  urea,  and  kreatin  are  present  in  larger  than  normal  quan- 
tities. As  the  flow  of  urine  increases,  the  thirst  becomes  propor- 
tionately pronounced,  and  the  amount  of  liquids  consumed  bears  a 
direct  relation  to  the  quantity  of  urine  voided. 

As  the  disease  progresses  the  skin  becomes  dry  and  harsh,  the 
nails  brittle,  and  the  temperature  subnormal.  The  general  condition 
of  the  patient  varies  considerably  in  different  cases.  Sometimes  the 
excessive  thirst  and  profuse  urinary  flow  are  about  all  the  symptoms 
noticed,  the  subject  maintaining  tolerably  good  health  otherwise. 
In  other  cases  digestive  derangements,  with  loss  of  appetite  and 
gastro-intestinal  disturbance  with  prostration  and  emaciation,  grad- 
ually advance.  Sometimes  vomiting  and  rapid  emaciation  attend, 
followed  by  cough,  hectic,  and  fully  developed  phthisis.  Salivation  is 
an  occasional  symptom,  and  it  may  persist  throughout. 

Diagnosis. — Polyuria  may  arise  in  other  diseases  besides 
diabetes.  Hysterical  persons  sometimes  void  large  quantities  of 
urine  in  a  short  time,  but  the  polyuria  is  of  short  duration,  at  erratic 
intervals.  In  diabetes  insipidus  the  profuse  discharge  is  constant, 
and  observation  of  a  patient  for  a  month  will  settle  the  question  as 
to  the  diabetic  nature  of  the  disease.  Absence  of  sugar  will  dis- 
tinguish it  from  diabetes  mellitus. 

Prognosis. — The  disease  may  continue  for  years,  without 
seriously  undermining  the  health.  Spontaneous  recovery  some- 


RICKETS.  333 

timea  occurs  during  the  course  of  acute  diseases,  and  death,  when  a 
fatal  issue  attends,  is  usually  the  result  of  intercurrent  affections. 
Spontaneous  recovery  is  rare. 

Treatment. — Whenever  the  cause  can  be  ascertained,  it  should 
be  removed.  The  skjn  should  be  warmly  clothed  in  flannels,  and  a 
warm  and  equable  climate  should  be  chosen  for  residence. 

The  medical  treatment  will  consist  of  those  agents  which  tend  to 
constringe  the  renal  capillaries,  either  by  direct  action,  or  through 
the  vaso motor  nerves.  Bhus  aromatica,  tycopus,  nitrate  of  uranium, 
faborandi,  and  other  agents^  have  been  used  with  varying  success,  to 
control  the  excessive  nrinary  flow.  As  the  disease  is  probably  nerv- 
ous in  origin  and  probably  often  reflex,  the  difficulty  of  directing 
the  specific  agent  to  the  point  of  irritation  is  apparent;  and,  even  if 
the  trouble  arise  from  lesiona  about  the  medulla,  we  are  at  a  loss  to 
prescribe  a  remedy  which  will  maintain  a  steady  and  permanent  con- 
trol over  it.  Olycerole  of  gallic  acid,  in  half-teaspoonful  doses,  some- 
times acts  beneficially  in  restricting  the  excessive  discharge  of  urine. 
A  solution  of  twenty  grains  of  quinine  in  an  ounce  of  tincture  of 
muriate  of  iron,  dose,  ten  drops  every  three  hours,  sometimes  serves 
a  good  purpose.  Phosphoric  acid  bears  an  excellent  reputation,  and 
is  reported  to  have  accomplished  numerous  cures.  Scitta  maritima, 
in  fractional-drop  doses,  sometimes  exerts  an  excellent  influence. 
Full  doses  of  valerian,  ergot,  antipyrine,  and  various  other  drugs, 
have  their  advocates. 

An  active  state  of  the  skin  is  advantageous,  and  this  may  be 
brought  about  by  the  use  of  the  cabinet  vapor  bath,  repeated  two 
or  three  times  weekly.  The  galvanic  current,  one  pole  at  the  nape  of 
the  neck  and  the  other  at  the  loins  may  be  tried,  but  its  efficacy 
is  doubtful,  even  though  it  is  highly  recommended. 

VII.  RICKETS. 

Synonyms. — Rhachitis;  Rachitis. 

Historical  Note. — The  term  rickets  is  supposed  to  be  either 
from  the  Saxon  word  "rick,"  a  hump,  or  from  a  Dorsetshire  verb 
"rucket,"  to  breathe  laboriously.  The  disease  was  first  described 
bv  English  writers,  and  the  first  case  noticed  appeared  in  Dorset- 
shire. Therefore  many  writers  retain  the  original  term,  "rickets,"  to 
designate  the  disease.  Those  of  more  classical  turn  prefer  the  term, 
"rhachitis,"  which  is  derived  from  a  Greek  word  signifying  spine. 

Definition. — A  constitutional  disease  affecting  children,  char- 
acterized by  disturbance  of  normal  processes  of  ossification,  attended 
by  enlargement  of  the  epiphyses,  with  softening  of  the  bones  and 
resulting  deformity. 


334  CONSTITUTIONAL  DISEASES. 

Etiology. — Three  periods  of  life  are  especially  liable  to  this 
disease,  viz.,  the  foetal  period,  the  infantile  period,  and  that  of  ado- 
lescence, malnutrition  being  responsible.  It  is  said  that  large  num- 
bers of  still-born  children  are  found,  upon  careful  investigation,  to 
be  rickety.  The  usual  period  for  the  development  of  the  disease  is 
between  the  sixth  month  and  the  third  year.  Both  sexes  are  equally 
susceptible,  statistics  showing  about  an  equal  number  to  be  affected. 
Heredity  plays  an  important  part,  though  constitutional  weakness  is 
all  that  can  be  claimed  in  this  respect.  Protracted  lactation  and 
repeated  pregnancies  lower  the  vitality  of  mothers,  the  younger 
children  of  large  families  being  more 'prone  to  rickets  than  the  older 
ones,  excessive  and  prolonged  lactation  resulting,  doubtless,  in  deteri- 
oration of  the  mother's  milk.  As  European  families  are  much 
larger,  as  a  rule,  these  facts  may  suggest  a  reason  for  the  greater 
prevalence  of  the  affection  in  Europe  than  in  America,  where  it  is 
comparatively  rare  except  among  children  of  European  immigrants, 
and  negroes.  Poor  ventilation,  dampness,  and  want  of  sunlight  are- 
believed  to  predispose  to  it,  especially  when  infants  are  weaned 
early  and  fed  upon  farinaceous  diet,  starchy  food  tending  to  the 
formation  of  lactic  acid.  The  disease  is  more  prevalent  in  large 
cities  than  in  rural  districts  or  small  towns. 

As  to  the  actual  condition  which  is  responsible  for  the  improper 
bony  development,  there  are  numerous  theories,  all  taking  for 
granted  that  there  is  a  lack  of  phosphate  of  lime  to  supply  the  devel- 
oping bones  with  the  proper  amount  of  earthy  material  somewhere. 
The  lactic-acid  theory  assumes  that  there  is  an  excess  of  lactic 
acid  generated  in  the  alimentary  canal  by  imperfectly  digested 
starchy  material,  and  that  this  removes  the  lime  destined  for  the 
bones  from  the  blood  in  the  form  of  soluble  salts,  and  irritates  the 
bones  at  the  same  time.  Others  have  asserted  that  insufficiency  of 
earthy  salts  in  the  food  gives  rise  to  it,  but  this  is  disputed,  as  rick- 
ets may  occur  under  the  best  of  conditions  of  this  kind.  Lack  of 
fats  and  proteids  in  the  diet  of  rhachitic  children  has  been  supposed 
to  be  responsible  for  it.  Syphilis,  malaria,  bronchitis,  and  other 
conditions  have  been  held  responsible  for  the  development  of  rickets, 
but  it  must  still  be  admitted  that  there  is  some  obscure  element  at 
work  in  most  cases  which  cannot  be  accounted  for,  and  that  the  spe- 
cific cause  is  yet  to  be  determined.  The  rickets  of  adolescence  is 
probably  a  result  of  an  infantile  attack  which  has  been  barely  warded 
off,  or  not  fully  recovered  from,  bu1;  which  has  remained  in  a  latent 
state  throughout  childhood,  and  developed  through  the  important 
systemic  changes  then  occurring. 


RICKETS.  333 

Pathology. — During  the  active  stage  the  most  marked  patho- 
logical changes  occur  at  the  points  of  junction  between  the  epiphyses 
and  shafts  of  the  long  bones.  The  cartilage  which  separates  these 
parts  is  normally  thin  (about  two  millimeters  in  thickness),  but  in 
rickets  it  becomes  expanded  into  a  thick,  reddish-gray,  translucent 
cushion,  while  the  adjacent  bony  structure  is  enlarged  and  softened. 
The  vascular  layer  which  underlies  the  periosteum  is  softened,  pulpy, 
and  thickened,  the  periosteum  itself  being  thickened  and  swollen, 
and  its  attachment  to  the  bone  more  than  ordinarily  tenacious ;  and 
a  pale-red,  pulpy  fluid  infiltrates  the  epiphyses,  periosteum,  and 
bones.  The  bones  of  the  skull,  the  ribs,  and  the  wrists  are 
most  frequently  involved,  the  proportion  of  inorganic  material  being 
very  much  decreased,  it  being  supposed  that  lack  of  phosphate  of 
lime  in  the  system  results  in  the  absorption  of  that  element  from 
bones  already  ossified  to  supply  growing  bones  in  the  developing 
child.  The  bones  become  soft  and  yielding,  bodily  weight  and  mus- 
cular action  tending  to  twist  them  out  of  their  normal  shape.  The 
liver  and  spleen  take  on  various  pathological  changes.  The  spleen 
becomes  engorged  and  enlarged,  and  the  liver  is  sometimes  affected 
with  fatty  infiltration.  The  lymphatic  glands  are  occasionally 
enlarged. 

When  the  process  of  ossification  begins  to  be  reestablished,  the 
bone  is  laid  down  so  rapidly  that  layers  of  new  formation  appear  on 
the  surface,  causing,  in  many  cases,  increased  deformity. 

Symptoms. — Rickets  is  usualty  the  outcome  of  a  protracted 
period  of  ill  health,  in  which  there  are  no  obviously  specific  symp- 
toms. The  child  will  be  noticed  to  be  pale,  restless  at  night,  with  a 
disposition  to  kick  the  bedclothing  off,  and  there  is  usually  a 
marked  tendency  to  relaxed  sweats,  especially  about  the  head.  It 
gradually  grows  pot-bellied,  the  tissues  becoming  flabby  and  inelastic, 
and  most  cases  manifest  a  general  tenderness  about  the  body,  the 
child  crying  out  with  pain  when  handled.  This  symptom  may  be 
so  marked  that  the  gentlest  effort  at  moving  the  patient  may  pro- 
voke intense  pain,  as  manifested  by  shrieks  from  the  sufferer.  The 
"paralysis  of  rickets"  may  now  become  developed,  the  child  losing 
the  ability  to  walk,  if  it  has  already  learned  to  do  so,  and  it  may  lose 
the  use  of  the  arms  as  well.  However,  there  is  no  real  nervous 
lesion  in  such  a  case,  the  inability  to  use  the  parts  depending  upon 
muscular  weakness  and  tenderness  of  the  bones  and  periosteum 
instead  of  lack  of  nervous  impulse.  This  condition  is  termed  "Par- 
rot's disease,"  and  precedes  the  marked  changes  in  the  bones,  and 
therefore  is  liable  to  be  confounded  with  latent  meningeal  or  spinal 
trouble. 


336  CONSTITUTIONAL  DISEASES. 

Sometimes  there  is  the  complication  of  bronchitis  with  these 
indications,  and  this  may  give  rise  to  elevation  of  temperature  and 
other  febrile  symptoms.  In  other  cases  the  chronic  disease  may 
develop  without  intercurrent  complication,  and  little  active  constitu- 
tional disturbance  be  manifested.  Thus,  acute  and  chronic  rickets 
have  been  described,  though  there  is  essentially  no  difference 
between  them,  except  as  the  incidental  complication  may  determine 
the  condition. 

After  a  somewhat  protracted  period  the  osseous  changes  begin  to 
appear.  Tlie  ribs  and  the  wrists  manifest  the  earliest  and  most 
marked  changes.  The  points  of  junction  between  the  ribs  and  cos- 
tal cartilages  protrude  as  a  "rosary"  of  bead-like  enlargements, 
readily  felt  upon  palpation,  and  the  wrists  assume  characteristic 
shapes,  enlargement  of  the  lower  extremeties  of  the  radius  and  ulna 
imparting  a  noticeable  bulging  to  the  parts.  The  typical  head  of 
rickets  is  now  gradually  developed.  The  forehead  becomes  high, 
square,  and  prow-shaped,  with  decided  prominence  of  the  frontal 
eminences;  the  parietal  eminences  may  also  be  prominent,  and 
the  skull  is  elongated.  The  intellectual  powers  are  not  necessarily 
retarded  by  rickets,  the  brain  usually  developing,  and  expanding  its 
functions  as  though  there  was  no  disease  present,  though  there  may 
be  exceptions  to  the  rule,  and  dementia,  idiocy,  or  imbecility  be  the 
condition.  The  face  of  a  rhachitic  child  is  large  above  and  diminu- 
tive below,  as  the  jaws  are  usually  small  and  the  lower  one  retracted, 
giving  the  chin  a  retreating  appearance.  This  affords  an  intelligent 
expression  to  the  countenance,  the  child  impressing  the  observer 
as  an  individual  of  precocity,  though  marks  of  ill  health  are  por- 
trayed by  the  enlarged  and  superficial  veins  of  the  scalp  and  fore- 
head, and  open  anterior  fontanelle.  The  sutures  of  the  skull  close 
more  slowly  than  usually,  and  a  gutter  may  be  left  along  their  course, 
following  ossification.  Dentition  is  also  delayed,  the  first  tooth 
appearing  about  the  ninth  month,  and  the  last  deciduous  tooth  about 
the  third  year.  When  developed,  the  teeth  may  present  the  charac- 
teristic appearance  described  as  " Hutchinson's  teeth." 

Thinning  or  wasting  of  the  tables  of  the  skull  may  occur,  until 
portions  of  its  surface  become  so  attenuated  as  to  yield  to  gentle 
pressure,  imparting  the  sensation  to  the  finger  of  the  crackling  of 
parchment  This  is  termed  "cranio-tabes."  It  is  not  often  observed 
in  this  country. 

Hypersemia  of  the  brain  and  meninges  is  liable  to  attend,  and 
hydrocephalus  is  extremely  apt  to  follow  such  a  condition. 

Deformities  of  the  chest  are  very  liable  to  attend  rickets,  and 
sometimes  a  condition  of  this  character  is  all  that  may  be  found  to 


HICKETS.  337 

attest  the  presence  of  the  disease,  or  its  results.  As  the  framework  of 
the  thorax  becomes  softened,  the  muscles  and  atmospheric  pressure 
tend  to  bend  the  bones  out  of  shape,  the  most  yielding  point  being 
at  the  costo-sternal  juuction.  Sometimes  the  thorax  is  flattened  lat- 
erally, the  sternum  being  projected  forward,  constituting  "pigeon 
breast,"  or  pectus  carinatum.  At  other  times  the  deformity  may  be 
unilateral,  one  side  yielding  more  than  the  other,  or  one  side 
being  depressed  and  the  other  bulging.  The  diaphragm  exerts  a 
tension  on  the  ribs  which  is  sometimes  marked  in  rickets,  a  line  of 
depression,  corresponding  to  the  points  of  its  attachment,  encircling 
the  thorax.  In  some  cases  the  results  of  the  distended  abdomen 
may  remain  after  the  bones  have  become  hardened  and  the  abdomen 
has  flattened,  the  lower  ribs  remaining  rolled  outward  and  upward, 
maintaining  a  peculiar  deformity. 

Spinal  curvature  is  common  in  this  disease,  three  forms  being 
described,  viz.,  kyphosis  (backward  curvature),  scoliosis  (lateral 
curvature),  and  lordosis  (forward  curvature). 

Softening  of  the  long  bones  may  result  in  bowing  of  the  forearm, 
bow-legs,  knock-knees,  etc.  The  sacrum  may  yield  to  the  pressure 
from  above  and  throw  the  direction  of  the  pelvic  axis  backward,  the 
condition  imparting  a  squatting  posture  to  the  person  when  standing. 
Almost  every  deformity  imaginable  may  arise  in  this  disease,  from 
distortion  of  the  bones. 

Diagnosis. — The  disease  should  be  suspected  when  a  child 
becomes  pallid,  with  doughy,  flabby  tissues,  and  tendency  to  profuse 
perspiration  about  the  head  habitually,  especially  at  night.  Such 
symptoms  are  sufficient  for  therapeutic  diagnosis  at  least,  and  they 
sound  a  warning  which  should  not  be  unheeded,  for  now  is  the  time 
to  administer  the  treatment  to  forestall  serious  osseous  changes. 
After  these  have  begun  a  short  time,  there  can  be  no  mistaking  the 
condition,  the  deformities  and  general  symptoms  combining  to  make 
the  picture  complete. 

Prognosis. — Permanent  dwarfing,  added  with  various  deform- 
ities, follows  the  subsidence  of  the  disease.  Many  of  the  lesser 
deformities,  such  as  enlargement  of  the  epiphyses,  diminish  with 
growth,  though  spinal  curvature,  pigeon  breast,  and  rhachitic  skull 
mark  the  results  of  the  disease  throughout  life.  During  its  course, 
various  complications  tend  to  fatal  results,  the  principal  of  these 
being  bronchitis,  broncho-pneumonia,  diarrhoea,  hydrocephalus,  and 
amyloid  degeneration  of  internal  organs.  Proper  treatment,  begun 
early,  usually  benefits  in  a  short  time. 

Treatment. — The  most  important  consideration  in  treatment 
is  attention  to  hygienic  methods.  If  the  child  be  nursing,  and  the 

23 


338  CONSTITUTIONAL  DISEASES. 

mother  seem  to  be  in  indifferent  health,  it  must  be  removed  from 
the  mother's  breast  and  a  healthy  wet-nurse  substituted.  Or,  if 
this  be  impossible,  it  should  be  put  upon  properly  prepared  cow's 
milk,  the  various  infant  foods  containing  too  much  sugar  and  dextrine 
for  such  children.  If  the  cow's  milk  be  sweetened,  sugar  of  milk 
and  not  cane-sugar  should  be  used.  The  child  should  be  kept  in 
the  open  air  much  of  the  time,  as  oxygen  and  sunlight  are  impor- 
tant aids  in  treatment. 

One  of  the  most  efficacious  medicines  is  calcarea  carh,  3x  tritu- 
ration,  administered  in  two-  or  three-grain  doses,  four  times  daily. 
This  is  especially  indicated  when  there  are  nocturnal  head-sweats, 
and  it  should  be  prescribed  immediately  upon  the  appearance  of 
this  symptom,  as  it  may  prove  prophylactic  against  further  develop- 
ment of  the  disease. 

Silica  3x  is  another  remedy  indicated  in  sweating  about  the 
head,  and  it  exerts  an  excellent  influence  over  reparation  of  bony  and 
cartilaginous  structures.  It  may  be  alternated  with  calcarea  carb. 
or  employed  alone,  with  good  results. 

Schuessler's  tissue  remedy  is  worthy  of  trial  in  rickets,  as  it 
often  proves  efficacious.  Calcium  phosphate  will  usually  act  better  in 
minute  doses  in  this  disease  than  in  the  large  ones  often  advised, 
and  the  3x  trit uration,  in  two-  or  three-grain  doses,  three  or  four  times 
daily,  is  worthy  of  confidence. 

Phosphoric  acid,  in  minute  doses,  phosphorus,  and  cod-liver  oil 
are  other  remedies  which  have  been  highly  recommended. 

The  tonic faradic  treatment  will  be  found  to  assist  the  action  of 
medicines  very  much  in  the  management  of  this  disease.  It  may  be 
repeated  two  or  three  times  a  week. 

vm.  SCURVY. 

Synonym. — Scorbutus. 

Definition. — A  chronic  constitutional  disease,  due  to  deficiency 
of  fresh  vegetable  and  animal  diet,  characterized  by  anaemia,  pros- 
tration, sponginess  of  the  gums,  and  tendency  to  hemorrhage. 

Etiology. — Scurvy,  in  times  past,  was  preeminently  a  disease  of 
the  sea,  the  crews  of  slow  sailing  vessels,  who  had  exhausted  their 
vegetable  food  and  lived  on  salt  pork  and  biscuits  for  a  long  period 
of  time,  being  the  ones  principally  affected.  In  these  times,  when  fa- 
cilities for  preserving  vegetables  in  hermetically  sealed  cans  for  an 
indefinite  period  has  become  perfected,  the  disease  is  comparatively 
rare.  Armies,  in  time  of  war,  are  sometimes  obliged  to  subsist  on 
salt  meat  and  hardtack  for  a  protracted  period  without  fresh  food, 


SCURVY.  339 

and  the  men  are  then  liable  to  contract  scurvy.  During  recent  times, 
the  miners  of  Alaska  have  been  the  most  common  sufferers,  depriva- 
tion of  fresh  vegetables  and  other  ingredients  supplied  by  them  be- 
ing very  common  to  that  country  during  the  winter  months.  Several 
cases  of  the  kind  have  been  at  the  Maclean  Hospital  within  the  past 
two  years,  all  Alaskan  miners  recently  landed  from  the  north. 

Considerable  difference  of  opinion  exists  as  to  the  identity  of  the 
specific  causal  factor.  Some  follow  Garrod  and  believe  that  absence 
of  the  potassic  salts  is  answerable  for  the  pathological  developments, 
while  others  believe  that  the  condition  arises  from  the  lack  of  mal- 
ates,  citrates  and  lactates,  from  which  the  carbonates,  which  render 
the  blood  alkaline,  are  derived.  At  any  rate,  a  gradually  diminishing 
alkalinity  of  the  blood  attends,  and  there  seem  to  be  good  grounds 
for  logical  reasoning  from  cause  to  effect  in  this  connection. 

Physical  influences,  outside  of  that  of  diet,  and  mental  states  un- 
doubtedly exert  a  certain  effect  in  the  production  of  the  disease. 
Homesickness,  especially  when  attended  by  other  depressinginfluences 
seems  to  lessen  the  resisting  power  of  the  system;  epidemics  of  the 
disease  on  convict  ships  in  olden  times,  and  in  prisons,  where  the 
diet  would  hardly  warrant  it,  go  far  toward  establishing  the  proposi- 
tion that  mental  influence  of  a  depressing  nature  is  an  important 
causal  factor. 

All  ages  are  liable  to  it,  though  elderly  persons  are  most  suscep- 
tible. Starvation  alone  seems  not  to  dispose  to  it,  as  scurvy  has 
never  followed  the  most  prolonged  fast;  only  those  who  eat  food  lack- 
ing the  proper  elements  being  attacked. 

Pathology. — There  is  decreased  alkalinity  of  the  blood,  which 
is  dark,  fluid,  and  does  not  coagulate  readily.  Deficiency  of  the  pot- 
ash salts  has  been  demonstrated.  The  capillaries  present  evidences 
of  alteration  of  the  endothelial  cells  and  are  choked,  in  places,  with 
red  corpuscles.  Ecchymosis  is  common,  the  skin  and  subcutaneous 
tissue,  the  muscles,  the  joints,  the  subperiosteal  tissue,  the  mucous 
and  serous  membranes  and  the  internal  organs  all  being  more  or  less 
involved.  Hemorrhages  occur  in  the  internal  organs,  especially  in 
the  kidneys  and  bladder.  The  gums  are  especially  involved,  being 
swollen,  spongy  and  hemorrhagic,  and  often  ulcerated,  even  so  that 
the  teeth  become  loosened  or  fall  out.  Parenchymatous  changes 
occur  in  the  spleen,  liver,  kidneys,  and  heart.  The  spleen  may  be 
markedly  enlarged  and  swollen. 

Symptoms. — The  disease  advances  insidiously.  Gradual  loss 
of  flesh,  with  prostration  and  pallor,  attract  first  attention.  Spongi- 
ness  of  the  gums  may  now  be  noticed,  these  parts  being  swollen,  ten- 
der, hemorrhagic,  and  fungous  in  appearance.  Loosening  of  the 
teeth  commonly  occurs,  though  the  affection  of  the  gums  is  not  always 


340  CONSTITUTIONAL  DISEASES. 

present.  The  tongue  is  swollen  and  livid,  ecchymosis  may  appear  in 
the  mucous  membrane  of  the  mouth,  and  the  breath  is  foetid  and  of- 
fensive. Sometimes  the  salivary  glands  are  swollen.  Ecchymoses 
may  now  be  observed  about  various  parts  of  the  cutaneous  surface ; 
these  are  first  seen  about  the  legs,  then  on  the  trunk  and  arms,  especi- 
ally about  the  hair-follicles.  These  may  be  minute,  purple  spots,  or 
may  be  larger,  and  may  cause  cutaneous  swelling.  The  face  appears 
bruised  and  swollen,  presenting  a  livid  appearance.  The  skin  is  dry, 
rough  and  generally  of  a  muddy  pallor,  though  it  may  be  sallow  and 
leaden  in  hue,  and  slight  blows  or  bruises  are  followed  by  extensive 
extravasations. 

Severe  darting  pains  affect  the  limbs,  especially  about  the  calves 
and  popliteal  spaces,  and  node-like  swellings,  from  deeply  seated  ec- 
chymoses,  often  appear  on  the  shins. 

The  circulation  is  feeble,  the  pulse  small  and  slow,  except  when 
there  is  excitement,  and  there  is  palpitation  of  the  heart,  with  anaemic 
murmurs,  and  dyspnoea  upon  slight  exertion.  Where  the  disease  is 
advanced,  syncope  may  follow  even  moderate  exertion.  Sleeplessness, 
disordered  vision,  and  other  nervous  disturbances  are  common. 

The  bowels  are  constipated,  and  the  urine  scanty,  often  albumin- 
ous, and  there  is  diminution  of  the  normal  ingredients,  except  phos- 
phoric acid  and  the  potash  salts. 

Diagnosis. — The  history  of  the  case  and  a  careful  inspection  of 
the  gums  will  distinguish  between  scurvy  of  these  parts  and  mercurial 
poisoning.  In  purpura  there  are  not  the  marked  lesions  of  the  gums 
that  usually  attend  scurvy,  and  they  occur  in  isolated  cases,  while 
scurvy  is  liable  to  appear  in  epidemics.  Purpura  also  resists  the 
restorative  influence  of  lime-juice,  while  this  agent  readily  relieves 
scurvy. 

Prognosis. — If  the  conditions  which  give  rise  to  the  disease  are 
removed,  and  it  is  not  far  advanced,  the  prognosis  is  good.  Death 
results  in  from  ten  to  fifteen  per  cent  of  cases,  gradual  heart-failure, 
meningeal  hemorrhage,  extravasation  into  serous  cavities,  intestinal 
inflammation,  and  other  intercurrent  conditions  usually  carrying  the 
patient  off.  When  complicated  with  syphilis  or  chronic  alcoholism, 
the  prognosis  is  less  favorable. 

Treatment. — When  fresh  vegetables  are  not  to  be  had  during 
long  intervals,  scurvy  is  to  be  feared,  and,  if  possible,  prophylaxis 
should  be  observed.  Hall  and  Kane  asserted  that  the  eating  of  raw 
meat  acted  as  a  preventative  of  scurvy  during  their  Arctic  experience, 
while  cooked  meat  would  not.  Raw  potatoes  have  been  used  for  the 
same  purpose  by  the  miners  of  Alaska,  and  with  good  effect,  accord- 
ing to  reliable  reports.  The  daily  consumption  of  a  small  amount  of 
lime-  or  lemon-juice  serves  the  best  purpose,  probably,  though  limes 


INFANTILE   SCURVY.  341 

and  lemons  are  not  always  to  be  had.  Other  antiscorbutics  are  mus- 
tard, radishes,  cabbage  and  water-cress. 

When  a  patient  is  seriously  sick  with  scurvy,  he  should  have  per- 
fect rest,  as  the  great  debility  of  the  heart  and  other  vital  organs  for- 
bids that  he  should  exert  himself  in  the  least  He  should  remain  in 
bed,  and  take  three  or  four  ounces  of  lime-juice  or  lemon-juice,  well 
diluted  in  water,  every  day.  On  account  of  the  tenderness  of  the 
gums,  the  food  should  be  liquid  in  form,  and  should  consist  of  beef 
tea,  meat  soups,  broths,  soups  thickened  with  vegetables,  milk,  and 
eggs.  Return  to  solid  food  should  be  gradual,  and  the  use  of  lemon- 
or  lime-juice  should  be  continued  for  a  prolonged  period  during 
convalescence. 

The  medicinal  treatment  should  consist  of  a  fifteen-drop  dose  of 
a  reliable  preparation  of  berberis  aquifolium,  administered  in  a  little 
water,  and  repeated  four  or  five  times  daily. 

INFANTILE  SCURVY  (BARLOW'S  DISEASE). 

IMPERFECT  adaptation  of  food  may  give  rise  to  scurvy  in  children, 
as  well  as  in  adults.  It  is  frequently  the  case  that  iuiants  and  young 
children  are  deprived  of  fresh  vegetables  and  their  immediate  deriva- 
tives until  a  scrobutic  condition  is  engendered.  An  infant  at  its 
mother's  breast,  or  fed  upon  fresh  cow's  milk,  though  not  taking 
vegetables,  derives,  from  this  source,  constituents  immediately  elab- 
orated from  them,  and  the  nourishment  is  properly  adapted  to  the  de- 
mands of  nature.  But  when  artificial  foods  are  employed,  or  the 
child  is  fed  upon  condensed  milk  (which  has  been  cooked),  and  no 
fresh  milk  or  other  fresh  food  is  employed,  scorbutic  conditions  are 
liable  to  arise,  in  the  midst  of  plenty. 

The  symptoms  resemble  those  of  scurvy  in  adults,  though,  as  the 
disease  will  not  occur  as  an  epidemic,  the  physician  may  overlook 
the  true  state  of  affairs.  The  skin  presents  a  muddy  pallor,  the  gums 
are  spongy,  and  a  purpuric  rash  appears  on  the  lower  extremities,  and 
later  bruise-like  ecchymoses  will  be  noticed  upon  various  parts  of  the 
cutaneous  surface.  Officious  practitioners  "may  attempt  to  cure  such 
cases  by  lancing  the  gums,  with  the  mistaken  idea  that  they  are 
swollen  from  efforts  at  dentition,  and  provoke  fatal  hemorrhage.  In 
one  case  of  this  kind  which  came  under  my  observation,  the  child 
continued  to  bleed  from  the  incision  for  two  weeks,  and  finally  died 
apparently  from  loss  of  blood.  There  is  probably  pain  and  tender- 
ness in  the  calves  and  other  parts  of  the  lower  extremities,  as  the 
child  cries  wh  u  they  are  moved  or  put  upon  the  stretch.  Obscure 
swellings  occur  upon  various  parts  of  the  lower  extremities,  due, 
probably,  to  extravasations  under  the  periosteum;  and  these  are  usu- 


342  CONSTITUTIONAL   DISEASES. 

ally  symmetrical  —  appear  upon  both  extremities  consecutively,  in 
about  the  same  location.  The  limbs  are  drawn  up  at  first,  but  later 
become  relaxed  and  lie  immobile  and  flaccid,  as  though  paralyzed, 
with  the  toes  turned  outward. 

The  anaemia  is  profound,  and  the  patient  is  extremely  prostrated 
and  asthenia  The  eyelids  are  puffy,  one  or  the  other  or  both  are 
ecchymosed,  and  protosis  or  falling  of  the  eyeballs  may  occur,  con- 
secutively, due,  doubtless,  to  ecchymoses  in  the  orbits.  There  may 
be  slight  elevation  of  temperature,  but  the  pulse  is  feeble  and  irregu- 
lar. The  general  aspect  of  the  child  will  be  suggestive  of  rickets, 
though  the  symptoms  will  be  much  more  accute  than  in  that  disease. 

Treatment. — Fresh  milk  should  at  once  be  substituted  for  arti- 
ficial foods.  If  the  infant  is  very  young  the  best  substitute  for  pre- 
pared foods  will  be  a  wet  nurse.  However,  it  is  not  always  possible 
to  obtain  such  a  substitute,  and  fresh  cow's  milk,  properly  diluted, 
and  sweetened  with  milk  sugar,  will  be  in  order.  It  has  been  noticed 
that  raw  meat  has  been  found  a  preventative  of  scurvy,  while  cooked 
meat  is  not ;  and  so  it  seems  to  be  with  cooked  milk — and  condensed 
milk  possesses  the  objection  of  having  been  cooked. 

Further  than  this  the  treatment  will  be  similar  to  that  for  adults 
affected  with  the  same  disease  Lemon-  or  lime-juice,  well  diluted, 
should  be  used  sparingly,  and  meat-juice  or  gravy,  with  seived  pota- 
to, potato-soup,  and  other  digestible  forms  of  vegetable  diet,  com- 
mensurate with  the  age  and  condition  of  the  child,  should  be  allowed. 

IX.   PTTRPURA. 

Purpura  is  a  disease  liable  to  attend  a  variety  of  pathological 
conditions.  Strictly  speaking,  it  is  the  term  applied  to  extravasa- 
tions into  the  skin  from  systemic  causes  apart  from  those  of  scurvy. 
Symptomatic  purpura  may  arise  as  a  concomitant  of  some  other  dis- 
ease, or  from  the  action  of  drugs  or  poisons.  It  may  arise  from  ma- 
lignant endocarditis,  pyaemia,  septicaemia,  typhus  fever,  measles  or 
small-pox.  The  rashes  which  attend  the  exanthemata  are  examples 
of  purpuric  eruptions.  Again,  it  may  be  toxic,  and  due  to  poisoning 
from  venomous  reptiles;  the  action  of  certain  drugs,  such  as  bromide 
of  potassium,  iodide  of  potassium,  copaiba,  quinine,  and  some  others. 
A  not  uncommon  form  of  symptomatic  purpura  is  that  which  arises  as 
a  complication  of  arthritic  disease,  and  this  may,  to  all  intents  and  pur- 
poses, be  a  severe  attack  of  inflammatory  rheumatism  attended  by  a 
purpuric  rash,  covering  the  legs,  and  even  the  body  and  arms.  In  other 
instances,  the  rheumatic  symptoms  may  not  be  so  marked,  and  may 
amount  only  to  muscular  pains.  A  form  of  rheumatic  purpura,  de- 
scribed as  peliosis  rheumatica,  or  Schonlein's  disease,  where  the  pur- 
puric symptoms  are  extreme,  amounting  to  oedema  of  the  skin,  with 


PURPURA.  343 

various  eruptive  characters,  such  as  wheals,  vesicles,  etc.,  complicated 
with  multiple  arthritis,  sore  throat,  and  elevation  of  temperature,  to 
101° — 102°  R,  sometimes  occurs. 

Cachetic  purpura  may  arise  during  the  progress  of  cancer,  tuber- 
culosis, Hodgkin's  disease,  albuminuria,  or  during  senility. 

Neurotic  purpura  may  appear  during  the  course  of  certain  nervous 
affections  attended  by  organic  changes  in  a  given  area  of  nerve  sup- 
ply. Locomotor  ataxia,  acute  myelitis,  and  severe  neuralgias  are 
instances  where  such  purpuric  conditions  have  arisen. 

Mechanical  purpura  may  attend  venous  stasis  of  any  form,  and 
may  occur  after  severe  vomiting,  paroxysms  of  whooping  cough,  or 
seizures  of  epilepsy.  In  these  cases  the  purpuric  spots  will  be  most 
likely  to  appear  in  the  face. 

Henock's  purpura  usually  occurs  in  children,  and  is  another  vari- 
ety of  symptomatic  purpura.  Various  portions  of  the  body  may  be 
affected,  and  the  disease  may  continue  for  years,  with  occasional  out- 
breaks between  periods  of  freedom.  The  lesions  may  occur  in  the 
skin,  in  the  intestinal  mucous  membrane,  in  the  joints  or  in  the  kid- 
neys. The  cutaneous  symptoms  may  consist  of  erythematous  erup- 
tions, instead  of  simple  purpura.  The  intestinal  lesions  may  be 
manifested  by  crises  of  pain,  vomiting  and  diarrhoea;  the  kidney  dis- 
turbances by  attacks  of  hemorrhagic  nephritis,  the  arthritic  compli- 
cations by  pain  and  swelling  in  the  joints. 

PURPURA  HEMOBRHAGICA. 

TRUE  purpura  is  recognized  by  pronounced  purpuric  spots  or  ec- 
chymoses,  with  hemorrhages  from  the  mucous  membranes.  It  is 
otherwise  known  as  morbus  maculosus  Werlhofi,  and  is  attended  by 
changes  in  the  blood-vessels,  or  in  the  blood  itself,  probably  both 
combined,  and  extravasations  into  the  connective-tissue  spaces  of  the 
rete  mucosum,  and  into  the  mucous  membranes.  The  serum  soon 
absorbs  from  the  skin,  leaving  the  red  corpuscles,  which  may  either 
undergo  gradual  absorption  or  degenerate,  leaving  a  permanent  pig- 
mentation. The  extravasated  blood  in  the  mucous  membranes  is 
liable  to  escape,  and  hemorrhages  from  the  mouth,  nose  and  other 
mucous  surfaces  may  attend.  Extravasations  into  the  serous  mem- 
branes sometimes,  though  rarely,  occur,  and  the  peritonoeum,  peri- 
cardium, pleurae  and  pia  mater  may  be  the  seat  of  purpuric  spots. 
The  muscles,  bones,  periosteum,  conjunctiva  and  retina  occasionally 
suffer  from  purpuric  extravasations. 

Symptoms. — Malaise  and  digestive  derangements  may  precede 
the  onset  of  the  disease  for  several  days  or  weeks.  The  eruption 
appears  suddenly,  coming  out  on  the  extremities  and  trunk  first  and 


344  CONSTITUTIONAL  DISEASES. 

usually  stopping  there,  though  the  head  and  face  may  also  be  affected. 
Bleeding  from  mucous  surfaces  may  now  set  in,  and  profound  anae- 
mia may  rapidly  develop  from  epistaxis,  hromateinesis,  or  haemopty- 
sis. Loss  of  blood  may  result  fatally,  or  cerebral  hemorrhage  may 
carry  the  patient  off.  Sometimes  the  disease  assumes  marked  malig- 
nancy, and  terminates  fatally  within  twenty-four  hours,  with  large 
purpuric  extravasations  in  the  skin.  Cutaneous  hemorrhages  and 
extreme  prostration  are  the  leading  symptoms,  bleeding  from  the 
mucous  membranes  being  absent  or  death  occurring  before  it  begins. 
This  is  termed  purpurafulrninans.  Recovery  is  gradual,  the  purpuric 
spots  disappearing,  in  favorable  cases,  in  ten  days  or  two  weeks. 

The  diagnosis  is  to  be  made  between  this  disease  and  scurvy,  and 
will  readily  be  made  in  adults,  who  have  been  necessarily  deprived 
of  fresh  vegetables;  though  in  children  more  care  is  required.  In 
scurvy  swelling  and  ulceration  of  the  gums  is  a  prominent  symptom, 
while  it  is  liable  to  be  absent  in  purpura.  It  will  hardly  be  con- 
founded with  malignant  forms  of  eruptive  fevers,  where  epidemic  ten- 
dencies and  a  high  temperature  are  readily  recognized. 

Treatment. — Symptomatic  purpura  should  be  managed  accord- 
ing to  the  special  condition  giving  rise  to  it  The  exanthemata  should 
be  recognized  and  properly  treated ;  and  rheumatic  purpura  will  yield 
to  treatment  for  ordinary  rheumatism.  A  study  of  conditions,  and 
proper  treatment  for  special  demands,  must  be  the  duty  of  the  attend- 
ing practitioner.  In  the  treatment  of  purpura  hemorrhagica  such 
remedies  as  berberis  aqui/olium,  cistus  canadensis,  arctium  lappa, 
corydalis,  etc.,  should  be  thought  of.  Where  hemorrhages  are  severe 
and  threatening,  erlgeron  canadensis,  may  be  of  service.  In  malignant 
forms,  such  agents  as  echinacea,  lacJiesis,  or  baptisia,  may  be  of  avail. 
Sometimes  ten  drops  of  tincture  of  muriate  of  iron  every  three  or 
four  hours  answer  a  temporary  purpose,  though  ferruginous  prepara- 
tions are  not  usually  to  be  depended  upon.  Ordinary  hemostatics 
may  fail  utterly  to  control  purpuric  hemorrhage,  though  it  may  be 
well  to  try  them. 

X.   SCROFULA. 

Definition. — Scrofula  is  a  term  applied  to  many  different  condi- 
tions of  the  system,  depending  upon  a  peculiar  diathesis  now  believed 
to  be  tuberculous.  On  this  account  most  medical  authors  ignore  the 
term,  and  consider  scrofula  as  a  form  of  tuberculosis. 

Etiology. — The  scrofulous  diathesis  is  usually  inherited,  and 
may  be  due  to  syphilitic,  intemperate  or  phthisical  progenitors.  The 
children  of  parents  closely  related  by  blood  are  liable  to  inherit  a 
scrofulous  tendency;  and  it  may  be  acquired  during  early  life,  through 
the  influences  of  bad  air,  food  and  other  antihygienic  surroundings. 


SCKOFULA.  345 

Symptoms. — If  scrofula  and  tuberculosis  are  not  identical,  they 
are  so  closely  related  as  to  be  interchangeable.  However,  subjects 
may  survive  scrofulous  inflammation  and  live  a  lifetime  afterward, 
where  tuberculosis  in  ordinary  form  would  soon  prove  fatal.  Extreme 
ckronicity,  with  tendency  to  caseous  degeneration,  are  its  leading  feat- 
ures. It  is  principally  a  disease  of  children,  and  is  manifested  by 
transparency  of  the  skin,  blue  veins,  lustrous  eyes,  precocity  of 
intellect  and  nervous  irritability.  Scrofulous  subjects  are  either 
markedly  of  the  encephalic  temperament,  or  else  are  of  the  lymphatic 
type,  in  which  case  they  have  large  heads,  coarse  features  and  thick, 
flabby  skins,  with  overproduction  of  fat  about  the  nose  and  upper  lip. 
Glandular  enlargements  are  early  characteristics  of  scrofulous  chil- 
dren, though  prior  to  these  developments  cutaneous  inflammations, 
of  chronic  character,  are  liable  to  appear,  especially  about  the  corners 
of  the  mouth,  upon  the  edges  of  the  eyelids  or  in  the  ears.  Tonsillar 
enlargements  are  common,  and  catarrhal  affections  are  difficult  to  cure 
and  tend  to  return  upon  slight  provocation.  Pharyngeal,  laryngeal 
and  bronchial  catarrh  are  induced  by  slight  causes,  and  in  little  girls 
vaginal  leucorrhoea  and  troublesome  vulvitis  are  not  uncommon. 
Slight  injury  to  the  joints  is  liable  to  result  in  suppurative  inflam- 
mation of  destructive  character,  and  caries  of  the  joints,  with  tuber- 
culous deposits,  often  develops  without  the  aid  of  traumatism. 

Diagnosis. — There  is  little  possibility  of  mistaking  scrofulous 
inflammation  for  any  other  disease.  The  diathesis  bears  its  evidence 
with  it,  and  the  chronicity  of  the  affection  aids  in  determining  its 
character.  Scrofulous  deposits  contain  tubercle  bacilli,  and  these 
are  also  found  in  inflamed  scrofulous  glands. 

Prognosis. — Scrofulous  children  often  pass  through  childhood 
to  adult  life  and  live  to  a  fair  old  age,  though  crippling  from  joint 
affections  is  not  rare.  Tuberculous  intestinal  disease,  acute  hydro- 
cephalus,  croup  and  pulmonary  diseases  are  very  liable  to  arise  in 
such  children. 

Treatment. — Prophylaxis  is  to  be  considered.  Blood  relations 
should  avoid  marriage  among  themselves ;  broken  down,  phthisical 
and  syphilitic  persons  should  not  marry  at  all. 

A  plain,  nutritious  diet,  with  plenty  of  open-air  exercise  in  sun- 
shine, should  be  encouraged.  Cutaneous  eruptions  should  be  met 
with  calcium  sulphide,  calcarea  phos.  and  berberis  aquifolium  orstillhi'jia 
sylvatica.  Affections  of  the  joints  are  best  met  by  radical  surgical 
measures.  Affections  of  the  lymphatic  glands  yield  best  to  calcium 
sulph.  or  calcium  fluoride,  though  such  vegetable  remedies  as  coryalis, 
phytolaccca,  stillingla,  berberis  aquifolium  and  other  reputed  alteratives 
are  not  to  be  neglected  here. 


346  CONSTITUTIONAL  DISEASES. 

XL  HEMOPHILIA. 

Definition. — A  constitutional  fault,  of  hereditary  character,  con- 
sisting of  a  tendency  to  uncontrollable  bleeding  upon  slight  provo- 
cation, and  even  spontaneously  in  many  instances. 

Etiology. — Haemophilia  is  a  systemic  fault  which,  in  the  major- 
ity of  instances,  is  transmitted  from  mother  to  son.  The  daughters 
of  such  a  mother  are  not  liable  to  be  bleeders,  but  the  male  children 
they  bear  will  probably  be  subject  to  haemophilia.  Thus  the  weak- 
ness is  handed  down  to  the  male  portion  of  the  family,  while  the  ten- 
dency to  transmit  the  weakness  is  entailed  upon  the  female  portion. 
While  the  sons  are  bleeders,  their  children  seem  to  be  exempt,  the 
disease  being  transmitted  through  the  female  alone.  This  rule  has 
its  exceptions,  and  there  is  undoubtedly  occasionally  a  female  subject 
who  proves  to  be  a  bleeder.  Therefore,  it  has  been  estimated  on  good 
authority  that  about  one  in  thirteen  of  the  subjects  of  haemophilia 
is  of  the  female  sex.  There  are  exceptions  to  the  rule  that  haemo- 
philia is  hereditary,  as  it  is  occasionally  acquired ;  though  just  the 
essentials  to  its  origin  from  healthy  stock  is  not  known. 

Pathology. — There  are  no  peculiarities  of  structure  about  the 
blood-vessels  of  subjects  of  haemophilia  usually,  though  in  some  in- 
stances anatomical  changes  have  been  found  in  the  capillaries.  Un- 
usual thinness  is  the  only  peculiarity  liable  to  then  attract  attention. 
Probably  lack  of  tonicity  is  more  at  fault  than  tenuity  of  structure, 
as  proper  tone  about  the  stomata  in  the  minute  vessels  would  be  im- 
portant in  the  control  of  capillary  hemorrhage.  Hemorrhages  have 
been  found  in  and  about  the  joints,  and  inflammation  of  the  syovial 
surfaces.  Possibly  the  morbid  state  may  depend  upon  some  peculiar 
fluidity  of  the  blood,  rather  than  upon  fault  of  the  bloodvessels. 

Symptoms. — Uncontrollable  bleeding  from  trivial  causes  is  the 
leading  feature  of  the  disease.  A  slight  scratch,  blow  or  cut,  the 
extraction  of  a  tooth,  or  even  epistaxis,  may  result  in  prolonged  and 
alarming  hemorrhage,  which  persistently  resists  all  ordinary  means 
of  relief. 

Sometimes  the  bleeding  is  traumatic  and  sometimes  spontaneous. 
Traumatic  bleeding  may  be  interstitial,  and  may  consist  of  petechiae 
and  ecchymoses,  as  well  as  bleeding  into  the  joints.  Spontaneous 
bleeding  may  occur  from  the  nose,  mouth,  stomach,  bowels,  urethra 
and  other  internal  organs,  as  well  as  from  the  skin,  at  various  points, 
such  as  the  navel,  vulva,  scrotum,  eyelids,  ears,  finger  tips,  etc. 

The  bleeding  is  a  capillary  oozing,  but  it  may  be  so  profuse  as  to 
occasion  rapid  dripping  of  blood  from  the  part  and  cause  speedy 
prostration.  Continuing  on,  day  after  day,  it  soon  becomes  alarm- 
ing, and  may  finally  result  in  fatal  syncope.  When  the  bleeding  is 


HEMOPHILIA.  347 

into  the  joints,  there  is  pain  and  swelling  not  unlike  the  symptoms  of 
rheumatism,  especially  if  it  is  accompanied  by  elevation  of  tempera- 
ture and  accelerated  pulse. 

Diagnosis. — Where  a  knowledge  of  the  family  history  can  be 
had,  the  diagnosis  will  be  much  simplified.  Prolonged  bleeding  from 
trivial  causes  will  hardly  occur,  except  in  purpura,  and  the  symptoms 
of  this  disease  are  not  likely  to  be  mistaken. 

Prognosis. — When  hsemophilic  manifestations  appear  very  early 
in  life,  the  outlook  is  less  favorable  than  when  they  are  deferred 
until  adult  life.  More  than  fifty  per  cent  of  boys  who  become  bleed- 
ers very  young,  in  a  given  number  of  cases,  die  before  the  seventh 
year.  It  is  believed  that  the  longer  a  bleeder  survives  the  greater 
chance  he  has  of  outgrowing  the  tendency.  In  female  patients  sub- 
ject to  haemophilia  the  menstrual  and  parturient  functions  are  fraught 
with  more  than  ordinary  danger. 

Treatment. —  Exciting  causes  should  be  avoided  as  much  as 
possible.  Boys  who  belong  to  haemophilia  families  should  avoid  ac- 
tive habits,  so  that  danger  from  traumatism  may  be  lessened.  The 
avocations  of  such  persons  should  be  selected  with  this  object  in 
view.  One  of  the  very  worst  cases  of  this  kind  I  ever  treated  was 
that  of  a  carpenter,  who  scratched  the  back  of  his  hand  slightly  with 
a  saw.  I  had  previously,  several  years  before,  treated  him  for  dan- 
gerous bleeding  following  the  extraction  of  a  tooth.  Tooth-extraction 
and  all  minor  surgical  operations  should  be  avoided  in  such  patients, 
as  far  as  possible. 

When  bleeding  has  begun,  absolute  rest  should  be  required,  and 
oil  of  erigeron  should  be  administered,  in  ten-drop  doses,  repeated 
every  hour  or  half-hour.  If  this  fails,  small  doses  of  carbo.  veg.  may 
be  tried.  Blius  aromatica  is  a  good  remedy,  though  the  oil  of  eriger- 
on has  proven  the  best  remedy  for  me.  Ergot,  gallic  acid,  tannin  and 
a  score  or  less  of  other  commonly  known  haemostatics  might  be  sug- 
gested, to  be  tried  in  their  turn,  as  there  is  no  known  specific.  Sub- 
sulphate  of  iron,  locally,  is  the  best  aid  to  internal  measures.  A  low 
diet  is  to  be  commended. 


SBOTIOI2  IV, 

DISEASES    OF    THE    DIGESTIVE    ORGANS. 


I.  DISEASES  OF  THE  MOUTH. 

HERPES  LABIALIS. 

THIS  affection  is  quite  a  common  one,  and  seldom  requires  atten- 
tion, as  it  is  self-limiting,  in  the  majority  of  cases.  It  often  appears 
with  a  cold,  and  a  common  name  for  the  condition  is  "cold-sores." 
Herpes  labialis  often  appears  during  the  course  of  cerebro-spinal 
fever,  as  well  as  in  the  course  of  other  fevers,  and  requires  no  special 
attention.  When  it  becomes  chronic,  or  persists  for  a  longer  time 
than  usual,  phytolacca  may  be  used  internally,  while  a  dilution  of 
grindelia  robusta  is  applied  locally.  R  S.m.  or  normal  tinct.  phyto- 
lacca, gtt.  x-xx,  aqua  ad.  fiv.  Dose,  a  teaspoonful  every  two  hours. 
R  Saturated  tinct.  grindelia  robusta  3!,  aqua  ad  ?i.  Apply  every 
three  or  four  hours.  In  long-standing  cases,  berberis  aquifolium  may 
act  better  internally  than  phytolacca. 

SIMPLE  STOMATITIS. 

THIS  is  the  commonest  form  of  inflammation  of  the  mouth,  and  all 
ages  are  subject  to  it.  It  usually  results  from  the  action  of  irritants, 
such  as  hot  or  highly-seasoned  food,  strong  drinks  or  tobacco.  In 
children,  dentition  or  gastro-intestinal  irritation  may  account  for  it. 
It  often  arises  during  the  acute  specific  fevers. 

There  is  redness  and  dryness  of  the  mucous  membrane  at  first, 
involving  a  greater  or  less  portion  of  the  oral  mucous  membrane,  with 
excess  of  secretion  later  on.  Burning  of  the  surface  attends,  with 
smarting  upon  attempts  at  mastication.  Sometimes  the  tongue  is 
swollen  and  furred.  There  may  be  slight  elevation  of  the  tempera- 
ture, especially  in  children,  although  constitutional  symptoms  are  not 
marked. 

The  treatment  will  consist  of  a  weak  dilution  of  glycozone,  ji  to 
boiled  water  fii,  or  31  of  grindelia  robusta  to  water  fiv,  used  as  a 
wash.  A  solution  of  chlorate  of  potassium  ji  to  water  fiv  often  an- 
swers well.  Internally,  R  Phytolacca  jss,  aqua  ad  fiv.  Dose,  a 
teaspoonful  every  hour.  The  local  applications  will  usually  be 
sufficient. 


DISEASES  OF  THE  MOUTH.  349 

APHTHOUS  STOMATITIS. 

Synynoms. — Follicular  Stomatitis;  Croupous  Stomatitis. 

Definition. — An  ulcerative  form  of  stomatitis  involving  the  mu- 
cous follicles  of  the  oral  mucous  membrane. 

Etiology. — Aphthae  may  attend  any  inflammatory  disease  of  the 
tongue  or  mouth,  though  age  and  hygienic  surroundings  may  exert 
an  influence.  It  most  commonly  occurs  among  children,  and  may 
even  appear  as  an  epidemic.  It  frequently  attends  the  acute  infec- 
tious diseases,  one  of  the  worst  epidemics  I  ever  saw  being  a  compli- 
cation of  chicken-pox.  It  is  quite  common  among  children  as  a  spo- 
radic and  idiopathic  affection,  and  may  be  caused  from  indigestible 
food  remaining  in  the  mouth,  unripe  fruit,  candy,  etc.  Cachetic  con- 
ditions and  bad  hygienic  surroundings  may  be  blameable  for  its  ap- 
pearance. Some  women  are  troubled  with  aphthous  ulcers  at  each 
menstrual  period,  and  pregnant  and  nursing  women  are  sometimes 
affected  by  a  stubborn  form. 

Pathology. — Semi-transparent  vesicular  elevations  appear  on 
the  mucous  surfaces  of  the  cheeks,  gums,  and  tongue  and  around  each 
of  these  is  a  reddened  base;  these  constitute  what  are  termed  "aph- 
thae." Sometimes  they  are  very  numerous,  studding  the  mucous 
membrane  thickly,  and  at  other  times  they  are  few  and  scattering. 
As  these  rupture  they  leave  irregular  ulcers,  which  heal  slowly.  If 
several  coalesce  they  form  a  single,  large,  irregular  ulcer,  which  may 
be  tardy  about  healing.  Sometimes  there  may  be  deeper  sloughing, 
and  the  submucous  tissues  are  excavated. 

Symptoms. — When  occurring  in  nursing  infants,  the  first  sign 
will  probably  be  a  refusal  to  take  the  nipple ;  and  if  the  child  at- 
tempts to  nurse  it  will  quit  often  and  cry  peevishly,  because  of  the 
pain  excited.  With  older  persons  mastication  is  painful  and  diffi- 
cult, and  the  taking  of  fruits  or  anything  sour  excites  excruciating 
pain ;  and  the  same  is  true  of  hot  food  or  drink.  Slight  febrile  ex- 
citement may  be  present,  the  submaxillary  glands  may  be  hardened 
and  swollen,  and  ptyalism  may  be  more  or  less  of  a  factor.  Children 
are  liable  to  suffer  from  a  diarrhoea,  as  a  complication. 

Treatment. — The  practice  of  treating  these  ulcers  by  the  appli- 
sion  of  caustics,  or  even  by  local  washes,  is  usually  unsatisfactory, 
though  a  weak  dilution  of  liydrozone  sometimes  assists,  when  used  as 
a  wash.  The  specific  treatment  consists  of  the  use  of  phytolacca, 
which  selectively  influences  the  oral  mucous  membrane  with  repara- 
tive  effect.  As  there  is  usually  more  or  less  febrile  complication,  the 
addition  of  aconite  to  the  prescription  is  advisable.  K  Specific 
phytolacca  gtt.  x-xxx,  specific  aconite  gtt.  i-vi,  aqua  ad.  fiv.  Admin- 
ister a  teaspoonful  every  hour.  Where  ptyalism  is  a  prominent  and 


350  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

persistent  feature  and  there  is  marked  disposition  for  the  vesicles  to 
coalesce  and  form  large,  ragged  ulcers,  jaborandi  is  an  important  rem- 
edy. Ten  or  fifteen  drops  of  the  specific  medicine  (or  any  other  re- 
liable form)  should  be  added  to  the  prescription  just  offered.  Nurs- 
ing sore  mouth  is  very  stubborn,  and  will  seldom  yield  to  such  treat- 
ment. Attenuations  of  lachesis  have  had  the  best  influence  here  of 
any  remedy  I  have  used. 

F(ETID  STOMATITIS. 

Synonyms. — Ulcerative  Stomatitis;  Putrid  Sore  Mouth. 

Definition. — An  ulcerative  form  of  stomatitis,  which  occurs  in 
crowded  communities,  like  jails,  camps,  etc.,  where  surroundings  are 
detrimental  to  health.  It  may  arise  from  the  use  of  a  community 
drinking  cup  or  similar  cause;  and  a  predisposition  to  it  is  encour- 
aged by  unwholesome  food,  bad  ventilation,  carious  teeth  or  those 
upon  which  there  is  an  accumulation  of  tartar.  Bacteriologists  be- 
lieve that  the  specific  etiological  factor  consists  of  a  microbe ;  and 
the  belief  has  been  entertained,  in  some  quarters,  that  the  disease  is 
identical  with  the  foot-and-mouth  disease  which  infects  cattle  and 
that  it  is  conveyed  in  the  milk.  Other  theories  have  been  advanced, 
but  no  positive  knowledge  exists  as  to  the  real  specific  causal  factor. 
It  sometimes  occurs  sporadically. 

Symptoms. — The  ulcerative  process  begins  at  the  margins  of 
the  gums  and  spreads  along  over  two  or  more  aveoli.  The  gums  and 
surrounding  mucous  membrane  become  swollen  and  spongy,  bleed 
easily,  and  ragged  ulcers  form  along  the  gingival  margin,  with  ten- 
dency to  rapid  increase  in  size.  The  breath  is  foul,  the  tongue  is 
coated.  There  is  severe  aching  and  throbbing  pain  in  the  mouth, 
which  is  intensified  and  becomes  burning  and  stinging  upon -taking 
food.  There  is  ptyalism,  usually  profuse,  and  the  submaxillary 
glands  are  swollen  and  tender.  Constitutional  symptoms  develop; 
there  are  dryness  of  the  skin,  elevation  of  temperature,  sleeplessness 
and  emaciation. 

Treatment. — Hydrozone  is  the  best  remedy  for  use  here,  though 
constitutional  treatment  may  be  required  to  assist  its  action.  The 
ulcers  should  be  treated  locally  with  it,  either  by  spraying  the  gums 
or  by  applying  it  witn  a  swab,  and  the  excavations  along  the  fangs 
of  the  teeth  should  be  deeply  syringed  with  it  by  the  aid  of  a  hypo- 
dermic syringe.  In  addition,  a  wash  of  it  should  be  used  in  the 
mouth,  for  general  cleansing  purposes.  The  drug  may  be  diluted 
with  one  or  two  parts  of  water,  though  at  first  full  strength  may  be 
used,  for  cleansing  deep  excavations.  In  connection  with  this,  ten  or 
fifteen  drops  of  a  reliable  preparation  of  echinacea  should  be  adminis- 
tered, for  its  systemic  effect,  and  repeated  every  hour  or  two. 


DISEASES  OF  THE  MOUTH.  361 

Berber  is  aquifolium  is  a  remedy  which  should  not  be  forgotten  in 
these  cases.  Chlorate  of  potassium  has  its  ardent  admirers,  though  I 
am  of  the  opinion  that  it  has  been  overrated.  I  have  never  tried 
the  local  influence  of  grindelia  robusta  here,  but  believe,  from  its  ef- 
fects in  other  forms  of  ulceration,  that  it  would  prove  highly  benefi- 
cial in  foetid  stomatitis. 

The  diet  should  be  liquid  in  form,  and  unirritating.  Milk,  raw 
eggs,  custards  and  other  semi-solid  and  easily-digested  foods  may  be 
be  taken  during  convalesence. 

MERCURIAL  STOMATITIS. 

Definition. — An  inflammation  of  the  mouth  due  to  the  specific 
influence  of  mercury  upon  the  tissues. 

Etiology. — Mercurial  ptyalism  is  a  common  affection  with  the 
patients  of  many  allopathic  physicians,  The  idea  that  mercury 
should  be  pushed  until  the  gums  are  "touched"  is  yet  in  favor  with 
many  of  them,  and  with  those  who  do  not  believe  that  ptyalism  is 
essential  belief  in  the  curative  effects  of  mercury  in  many  conditions 
is  a  common  one.  Consequently,  mercurial  poisoning  frequently  oc- 
curs, and  occasionally  an  Eclectic  is  called  upon  to  administer  relief 
in  such  cases. 

Symptoms. — The  patient  may  complain  of  a  metallic  taste  and 
profuse  dribbling  of  saliva.  Upon  inspection  the  gums  will  be  found 
swollen,  reddened,  dusky  and  sensitive  upon  mastication.  The  breath 
is  offensive,  and  ptyalism  soon  becomes  a  disgusting  annoyance  to  the 
patient.  As  the  disease  continues  the  tongue  becomes  swollen,  the 
submaxillary  glands  enlarged  and  tender,  and  the  gums  may  ulcerate 
along  their  gingival  margins.  Caries  of  the  aveoli,  with  frequently 
recurring  gum-boils  and  premature  decay  of  the  teeth,  is  likely  to 
be  a  remote  result. 

Treatment. — Minute  doses  of  jaborandi  offer  as  good  results  as 
any  remedy.  Add  from  ten  to  fifteen  drops  of  specific  jaborandi  to 
half  a  glass  of  water  and  order  a  teaspoonful  every  two  or  three  hours. 
Phytolacca  is  also  an  excellent  remedy,  though  not  as  reliable  as  jabo- 
raudi.  Add  twenty  drops  of  the  saturated  tincture  to  half  a  glass  of 
water  and  order  a  teaspoonful  every  three  hours.  Chlorate  of  pot  as- 
sium,  used  as  a  wash,  is  in  great  favor  with  some,  and  it  is  claimed 
that  it  exerts  an  antidotal  influence  against  mercury.  Diluted  hydro- 
zone  should  not  be  forgotten,  and  if  other  remedies  fail  try  grindelia 
robusta.  fy  Specific  robusta  gii,  aqua  fiv.  Gargle  frequently. 

The  diet  should  be  bland  and  unirritating,  and  of  such  form  as  to 
be  easily  masticated.  In  bad  cases  the  diet  should  be  liquid  in  form, 
and  free  from  acids  and  high  seasoning. 


352  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

ECZEMA  OF  THE  TONGUE. 

Synonyms. — Map  Tongue  ;  Geographical  Tongue. 

Definition. — A  desquamation  of  the  epithelium  of  the  tongue, 
which  occurs  in  circinate  patches,  imparting  to  the  surface  of  the 
organ  a  map-like  appearance. 

Etiology. — The  etiology  is  obscure,  ordinary  causes  of  eczema 
of  the  skin  being  at  the  foundation  of  the  trouble.  It  occurs  most 
frequently  in  children,  though  adults  are  subject  to  it.  Some  regard 
it  as  a  gouty  manifestation,  though  this  is  not  probable.  Indigestion 
may  attend  it,  and  possibly  the  condition  may  be  due  to  gastric  dis- 
turbances. 

Symptoms. — The  patchy  tongue  presents  a  striking  appearance, 
and  attention  is  thus  often  called  to  it.  Sometimes  there  is  itching 
and  heat  upon  the  affected  surface,  but  mental  perturbation,  from 
fear  of  more  serious  developments,  is  the  unpleasant  feature  of  many 
cases. 

Treatment. — Thus  far  treatment  for  this  affection  has  afforded 
little  satisfaction.  The  continued  use  of  berberis  aquifolium  may  re- 
lieve the  burning,  when  this  is  present,  and  even  restore  the  normal 
appearance.  Graphites  has  relieved  one  case  which  I  have  observed, 
though  it  has  proven  futile  in  others.  Calc.  phos.  3x  is  worthy  of  a 
trial.  "Where  specific  remedies  fail  to  relieve,  attention  to  the  gen- 
eral health  will  be  commendable.  Such  cases  are  chronic,  and  nat- 
urally recuperate  slowly. 

PARASITIC  STOMATITIS. 

Synonyms. — Thrush;  Muguet;  Soor. 

Definition. — A  fungous  disease  of  the  mucous  membrane  of  the 
mouth. 

Etiology. — Thrush  is  a  fungous  growth  which  develops  from 
transplantation  of  the  oidium  albicans,  a  yeast-like  fungus,  which  af- 
fects children  most  commonly,  but  to  which  adults,  when  greatly 
debilitated,  may  become  subject. 

Pathology. — The  development  of  the  oidium  albicans  and  its 
parasitic  companion  studs  the  mucous  membrane  of  the  mouth  with 
patches  of  pultaceous,  creamy  masses,  which  may  coalesce  until  the 
surface  of  the  tongue  and  buccal  cavities  are  largely  covered  with  it. 
In  children  the  palate  is  a  favorite  place  for  its  lodgment.  The  epi- 
thelium of  the  mucous  membrane  becomes  loosened,  secretion  is 
arrested,  and  the  part  becomes  dry  and  dusky.  The  oidium  albicans 
consists  of  spores  and  filaments  resembling  the  yeast  plant  in  certain 
respects. 


DISEASES  OF  THE  MOUTH.  353 

Symptoms. — The  mouth  becomes  hot  and  sensitive.  There  is 
dryness  of  the  mucous  membrane,  though  the  action  of  the  salivary 
glands  may  be  increased,  with  acidity  of  the  secretion.  The  mucous 
membrane  becomes  swollen,  the  lips  everted.  Patches  of  thrush  in- 
crease in  size,  thus  forming  a  membrane  which  can  be  scraped  off, 
leaving  the  mucous  surface  more  or  less  excoriated  and  sensitive. 
The  buccal  mucous  membrane,  the  lips,  the  roof  of  the  mouth  and 
even  the  fauces  and  tonsils  may  become  affected,  the  whitish  incrus- 
tation covering  more  or  less  of  their  surface  with  ragged  patches. 
Sometimes  the  disease  extends  to  the  oesophagus,  and  even  the 
stomach  and  bowels  may  be  invaded  and  troublesome  diarrhoea, 
with  flatulence  and  green  stools,  attend. 

A  microscopical  examination  will  settle  disputes  in  diagnosis,  the 
distinctive  features  of  the  oidium  albicans  being  thus  determined. 

Treatment. — Careful  attention  must  be  paid  to  the  diet,  espe- 
cially in  cases  of  children  fed  upon  the  bottle.  Everything  should 
be  kept  carefully  cleansed — bottles,  tubes  and  nipples — and  no  sour 
or  fermented  food  should  be  allowed.  Sometimes  a  radical  change 
in  the  character  of  the  food  used  will  be  imperative.  The  substitu- 
tion of  a  wet  nurse  may  sometimes  be  necessary.  Antiseptic  mouth- 
washes  must  be  assiduously  employed,  and  diluted  listerine,  weak 
lime-water,  or  weak  solutions  of  bicarbonate  of  sodium  may  be  used. 
In  adults,  weak  solutions  of  equal  parts  of  carbolic  acid  and  glycerine 
or  diluted  hydrozone  may  be  needed,  to  cleanse  the  mouth  frequently. 

Constitutional  treatment  is  important,  special  remedies  adapted 
to  particular  cases  being  called  for.  Hygienic  surroundings  are 
desirable,  and  where  many  children  have  been  crowded  together 
isolation  in  healthy  localities  is  desirable.  Care  should  be  observed 
in  the  use  of  spoons,  nursing-bottles  and  other  feeding  implements, 
that  the  contagium  be  not  conveyed  to  healthy  subjects.  Aconite 
and  phytolacca  will  be  appropriate  to  relieve  the  irritation  of  the 
mucous  membrane. 

GANGRENOUS  STOMATITIS. 

Synonyms. — Cancrum  Oris;  Noma. 

Definition. — An  affection  occurring  in  children,  characterized  by 
rapid  and  progressive  gangrene  of  the  side  of  the  face,  having  for  its 
starting  point  the  gums  or  cheek. 

Etiology. — This  hideous  malady  has  for  its  principal  factor  the 
effects  of  mercury.  Allopathic  authorities  fail  to  state  this  fact  in 
their  treatises  on  medical  practice,  but  I  have  never  known  it  to  occur 
except  in  children  who  have  been  previously  mercurialized.  The 
prostration  following  acute  fevers  may  favor  its  development  and 
21 


354  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

ravages,  as  may  also  unsanitary  conditions,  but  the  irritating  and 
debilitating  influence  of  mercury  on  the  tissues  involved  in  the  start 
undoubtedly  gives  rise  to  it. 

Symptoms. — The  mucous  membrane  of  the  gums  or  cheek  of 
the  affected  side  is  first  attacked  by  ulceration  of  phagedenic  charac- 
ter, a  deep,  sloughy  ulcer  in  the  part  being  the  first  symptom  noticed. 
As  this  rapidly  spreads,  the  adjacent  skin  and  underlying  tissues 
become  indurated  and  purplish,  and  the  sloughing  continues  to  ex- 
tend until  the  cheek  is  perforated.  Sometimes  the  entire  cheek  melts 
away,  the  ulceratiou  extending  to  the  chin  and  tongue,  and  even  the 
eyelids  and  ears  may  be  involved. 

Marked  constitutional  symptoms  are  developed  as  the  e»«e  pro- 
gresses. The  temperature  rises  to  103°  to  104°  R,  the  pulse  becomes 
accelerated,  and  grows  feeble  later  on,  nausea  and  diarrhoea  super- 
vene and  profound  prostration  and  death  finally  follow.  In  other 
cases  the  sloughing  gradually  ceases,  leaving  the  patient  with  ;i  ghast- 
ly, grinning,  skeleton-like  aspect  upon  one  side,  the  teeth  and  gums 
being  exposed  as  far  back  as  the  angle  of  the  lower  jaw.  Other  cases 
may  be  arrested  before  the  destructive  action  has  progressed  so  far. 

Treatment. — Eckinacea,  both  locally  and  internally,  is  the  best 
agent  with  which  I  have  had  extended  experience  in  phagedenic  ulcer- 
ation. In  such  a  case  as  this  the  system  should  be  well  saturated 
with  it,  and  it  should  be  applied  to  the  part  constantly.  Ten  drops 
may  be  administered  every  hour,  and  a  twenty-five  per  cent  dilution 
in  water  should  be  kept  in  contact  with  the  part,  on  compresses. 
Hydrozone  spray  is  another  excellent  local  remedy. 

From  the  very  favorable  reports  received  of  the  use  of  preserved 
bovine  blood  (bovinine)  in  phagedenic  ulceratiou,  I  would  expect  it 
to  benefit  here.  It  might  be  used  locally,  either  on  antiseptic  gauze 
or  injected  into  the  affected  tissues,  while  the  proper  dose  was 
employed  internally.  It  might  be  used  in  connection  with  echinacea 
(or  Lloyd's  echafolta).  Griudelia  robusta  ji  to  aqua  fii  might  be 
found  a  useful  adjunct,  if  applied  locally. 

PYOBRHCEA  ALVEOLARIS. 

Definition. — This  term  strictly  signifies  suppuration  of  the  alve- 
oli, but  is  here  limited  to  a  peculiar  kind  of  inflammation  of  the  alve- 
oli and  surrounding  soft  structures  characterized  by  the  deposit  of 
a  dark,  slate-colored  material  on  the  roots  of  the  teeth,  with  rather 
wide-spread  inflammation  of  an  insidious  character,  the  teeth  becom- 
ing loosened  and  the  gums  destroyed,  without  much  pain  or  well- 
marked  sensitiveness.  It  is  distinct  from  the  disease  caused  by  the 
depositation  of  calcareous  material  about  the  fangs  of  the  teeth  (tar- 


DISEASES  OF  THE  MOUTH.  355 

tar)  and  distinct  from  alveolar  abscess,  which  is  usually  confined  to 
the  space  lying  at  the  extremity  of  a  single  fang. 

Etiology. — The  exciting  cause  of  the  disease  is  the  slate-colored 
deposit,  the  origin  of  which  is  still  in  doubt.  It  has  been  ascribed 
to  serumal  deposit  of  a  gouty  nature,  from  the  fact  that  uric  acid  has 
sometimes  been  found  in  it,  but  this  is  insisted  on  as  being  accidental 
by  competent  persons,  and  the  theory  of  a  gouty  origin  now  seems  to 
be  pretty  well  disposed  of  in  the  negative.  The  practice  of  adminis- 
tering mercury  to  salivation  doubtless  has  something  to  do  with  a 
loss  of  vitality  about  the  affected  parts,  which  predisposes  them  to 
afford  lodgment  to  the  incrustation,  and  the  impaction  of  particles 
of  food  may  cause  thrombus  of  the  pericementum,  with  subsequent 
transformation  of  the  arrested  blood  into  earthy  material.  It  seems 
to  involve  the  entire  thickness  of  the  pericementum,  and  is  firmly 
attached  to  the  cementum  (which  invests  the  dentine  of  the  faug). 

Pathology. — The  concretion  usually  scales  off  the  cementum 
readily  about  the  shaft  of  the  fang,  but  at  its  point  or  extremity  the 
cementum  is  roughened,  and  the  removal  of  the  morbid  accumula- 
tion requires  the  assistance  of  chemicals,  in  addition  to  instrumental 
means.  The  presence  of  the  foreign  body  gives  rise  to  irritation  of 
the  gingival  margin,  and  the  gum  gradually  shrinks  away  from  the 
fang,  leaving  it  exposed  and  finally  revealing  the  dark  incrusta- 
tion. The  soft  tissues  in  the  sockets  become  gradually  involved,  and 
the  bone  is  attacked  later,  concealed  pockets  of  pus  forming  about 
the  fangs  in  the  aveoli,  until  the  teeth  become  loosened,  the  gingival 
margins  soft  and  spongy  and  the  soft  structures  about  the  apices  of 
the  fangs  honeycombed  by  burrowing  suppurative  action.  The  teeth 
may  finally  drop  out,  the  patient  suffering  so  little  pain  as  to  scarcely 
realize  that  they  are  being  destroyed. 

Symptoms. — The  disease  is  insidious.  Slight  reddening  of  the 
edges  of  the  gums  will  be  the  first  symptom  noticed,  and  if  these  are 
now  slightly  retracted  the  slate-colored  deposits  will  be  found  just 
below  the  gingival  margin,  out  of  sight  of  superficial  inspection. 
These  are  small  at  first,  but  they  gradually  involve  more  or  less  of 
the  entire  surface  of  the  fang,  spreading  destruction  to  the  structures 
of  the  sockets  as  they  advance,  though  there  is  little  pain  or  ten- 
derness to  attract  attention.  Sponginess  of  the  gums  and  loosening 
of  the  teeth  are  later  developments,  and  finally  the  teeth  fall  out  from 
destruction  of  their  attachment.  If  a  probe  be  passed  down  along 
the  sides  of  the  teeth,  cavities  will  be  found  between  the  fangs  and 
alveoli  and  extending  into  the  gums. 

Treatment. — The  best  plan  to  pursue  is  to  refer  the  patient  to 
a  competent  dentist.  However,  there  may  be  circumstances  where 
it  will  not  be  practical  for  the  patient  to  reach  a  dental  office,  and 


356  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

the  physician,  in  such  cases,  should  know  how  to  manage  the  affec- 
tion. 

Destruction  of  the  pus  and  cleansing  and  stimulating  of  the  cavi- 
ties should  be  a  prominent  part  of  the  treatment  The  removal  of 
the  incrustation  is  imperative,  in  order  that  a  cure  may  follow. 
Hydrozone  should  be  injected  into  all  the  cavities  by  means  of  a  hypo- 
dermic syringe,  the  needle  of  which  may  be  converted  into  a  blunt 
tube  by  removal  of  the  point.  The  hydrozone  may  be  diluted  by  the 
addition  of  an  equal  part  of  boiled  water  at  first,  if  it  causes  pain  in 
full  strength,  and  it  should  be  warmed  before  use,  as  cold  solutions 
are  unpleasant  to  the  sensitive  structures.  Removal  of  the  incrusta- 
tion must  be  accomplished  with  minute  scrapers  or  chisels,  obtain- 
able at  any  dental  depot.  The  scraper  is  curved  near  the  point  and 
the  fang  is  raked  from  the  point  toward  the  crown,  while  the  chisel 
is  straight  and  the  motion  is  from  the  crown  toward  the  extremity  of 
the  fang.  Repeated  operations  should  be  practiced  in  order  to  ac- 
complish the  complete  removal  of  the  accumulation,  a  delicacy  of 
touch  thus  being  attained  which  will  enable  the  operator  to  detect 
the  presence  of  a  particle  of  the  accumulation  when  it  cannot  be 
seen.  The  repeated  use  of  hydrozone  will  gradually  loosen  masses 
which  are  at  first  firmly  adhered,  and  every  treatment  with  it  should 
be  followed  with  a  search  over  each  affected  fang  for  incrustations. 
Finally  each  operation  should  be  concluded  by  the  insertion  of  a 
mixture  of  equal  parts  of  fluid  extract  of  quercus  alba  and  oil  of  cinna- 
mon into  every  cavity  and  along  the  fang  of  every  affected  tooth,  the 
application  being  made  by  dipping  a  small  chisel  into  the  mixture 
before  each  probing. 

Success  in  treatment  depends  on  perseverance  and  attention  to 
details.  Several  weeks  of  the  use  of  hydrozone  and  search  for  incrus- 
tations are  necessary,  the  applications  being  made  every  other  day 
at  least.  As  treatment  progresses  the  swelling  of  the  gums  subsides, 
the  teeth  become  more  firmly  fixed  and  tenderness  disappears.  The 
teeth  should  be  inspected  at  intervals,  however,  for  a  long  time  after- 
ward, in  order  to  avoid  a  return  of  the  disease. 

IL   DISEASES  OF  THE  SALIVAEY  GLANDS. 

HYPERSECRETION  OF  THE  SALIVABY  GLANDS. 

Synonym. — Ptyalism. 

Etiology. — Ptyalism  occurs  under  a  number  of  conditions.  One 
of  the  most  common  causes  is  the  abuse  of  mercury,  weeks  of  excess- 
ive salivary  action  following  some  cases  of  unfortunate  mercurializa- 
tion.  Pregnancy  is  another  condition  where  excessive  action  of  the 


DISEASES  OF  THE  MOUTH.  357 

salivary  glands  may  prove  a  source  of  annoyance.  Some  vegetable 
agents  provoke  ptyalism,  jaborandi,  muscarin  and  tobacco  being 
notable  examples,  though  their  effects  are  usually  transient.  Ptyal- 
ism may  occur  during  the  course  of  some  acute  fevers,  though  the 
opposite  is  the  rule.  Small-pox  is  occasionally  attended  by  it. 

Symptoms. — The  symptoms  are  unmistakable.  The  mouth, 
however  frequently  emptied,  continues  to  fill  with  saliva,  which  is 
thin  and  watery,  dribbles  upon  the  chin  and  is  thus  a  source  of  con- 
tinual vexation.  Irritation  of  the  mouth  and  lips  often  attends,  and 
speech  is  interfered  with  by  the  provoking  presence  of  excessive  fluid 
in  the  buccal  cavity. 

Treatment. — The  successful  treatment  of  the  ptyalism  from 
mercury  is  often  attended  by  a  great  deal  of  difficulty.  The  salivary 
glands  frequently  seem  so  debilitated  and  relaxed  that  ordinary  reme- 
dies for  pytalism  fail  to  produce  much  effect.  Small  doses  of  jabo- 
randi, repeated  frequently,  sometimes  succeed.  R  Specific  jabo- 
randi gtt.  x.  aqua  fiv.  M.  Sig.  A  teaspoonful  every  two  hours. 
Hydrastis  does  well  here,  though  it  will  often  fail.  The  galvanic  cur- 
rent sometimes  succeeds  rapidly,  and  is  usually  very  successful  in  the 
ptyalism  of  pregnancy.  Take  an  ordinary  tongue  depressor  and,  lay- 
ing it  on  the  tongue  of  the  patient,  bring  in  contact  with  the  other 
part  (if  it  be  metal)  the  metal  terminal  of  a  conducting  cord  con- 
nected with  the  negative  pole  of  a  galvanic  battery,  the  patient  hold- 
ing, meantime,  a  wetted  sponge  attached  to  the  positive  pole  in  one 
of  her  hands.  The  current  should  be  about  four  or  five  milliamperes 
in  strength  (about  eight  or  ten  four-ounce  zinc-carbon  cells,  in  good 
order).  After  holding  it  there  a  few  seconds  remove  it,  to  allow  the 
patient  to  rest  the  tongue,  then  repeat  once  or  twice  afterward  in  the 
same  order.  Repeat  this  treatment  every  other  day  for  a  week  or 
more.  Sometimes  the  positive  to  the  tongue  will  be  more  satisfac- 
tory. Faradism,  used  in  the  same  manner,  sometimes  succeeds, 
though  it  is  not  as  positive  as  galvanism. 

ARREST  OF  THE  SALIVARY  SECRETION. 

Synonym. — Xerostoma. 

Etiology. — This  is  supposed  to  be  due  to  disturbance  of  the 
function  of  the  salivary  nerve  center.  A  majority  of  the  cases  which 
have  occurred  have  been  in  female  subjects  and  accompanied  by 
nervous  phenomena.  The  disease  is  very  rare. 

Symptoms. — The  symptoms  are  purely  local,  the  general  health 
rarely  being  disturbed.  There  is  remarkable  dryness  of  the  tongue, 
mucous  membrane  of  the  cheek  and  palate.  The  tongue  is  parched 
and  dry,  sometimes  cracked,  and  the  remaining  mucous  membrane 


358  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

of  the  mouth  is  smooth,  dry  and  shining.  Mastication  and  degluti- 
tion are  attended  with  difficulty,  the  mouth  becoming  clogged  by 
remnants  of  food  adhering  to  the  gums. 

Treatment. — The  only  successful  treatment  that  leaves  perma- 
nent results  is  by  the  use  of  galvanism  as  described  under  the  treat- 
ment of  ptyalism.  Here  the  negative  pole  should  invariably  be  ap- 
plied to  the  tongue.  Jaborandi  may  temporarily  promote  the  action 
of  the  salivary  glands,  though  here  it  is  given  in  ten-drop  doses  of 
the  specific  medicine,  or  in  still  larger  quantities. 

INFLAMMATION  OF  THE  SALIVARY  GLANDS. 

THIS  may  occur  under  different  circumstances  and  require  consid- 
eration from  various  standpoints.  Specific  parotitis  has  already  been 
discussed  among  the  specific  infectious  diseases.  Symptomatic  paro- 
titis occurs  from  a  variety  of  influences.  It  may  arise  during  the 
infectious  fevers,  either  from  continuity  of  oral  inflammation  along 
the  salivary  duct  or  from  septic  inflammation  through  the  blood.  Sup- 
puration usually  attends  an  inflammation  of  this  character,  active 
inflammatory  action  following.  Another  condition  in  which  sympto- 
matic parotitis  may  ensue  is  that  following  facial  paralysis  with 
peripheral  neuritis. 

Injuries  or  disease  of  the  abdomen,  pelvis,  kidueys  or  genital 
organs  are  sometimes  attended  by  parotitis,  also  such  diseases  as 
ulceration  of  the  stomach  and  such  injuries  as  blows  upon  the  testi- 
cles, the  introduction  of  a  pessary,  a  surgical  operation  on  these  parts 
or  other  pelvic,  genital  or  abdominal  organs.  In  these  cases  the  eti- 
ology is  not  well  defined,  though  probably  the  causes  are  septic  in 
nature. 

In  the  treatment  of  such  cases  small  doses  of  Jaborandi  or  potas- 
sium chloride  3x,  in  connection  with  a  mild  current  of  galvanism  or 
faradism,  may  bring  about  resolution  and  avert  suppuration.  When 
this  becomes  inevitable,  warm  poultices  should  be  employed  until 
evidences  of  suppuration  are  present,  and  early  incision  for  the  evac- 
uation of  pus  should  then  be  practiced. 

in.    DISEASES  OF  THE  PHARYNX. 

ACUTE  PHARYNGITIS. 

Definition, — An  acute  inflammation  of  the  mucous  membrane 
of  the  pharynx  and  adjacent  surfaces. 

Etiology. — This  is  a  catarrhal  condition,  due  to  sudden  changes 
which  give  rise  to  colds,  the  pharynx  being  a  favorite  place  for  the 
location  of  the  irritation  in  those  who  are  apt  to  clear  the  throat 


DISEASES  OF  THE  PHARYNX.  359 

often  by  hawking  and  empty  swallowing,  when  there  exists  a  slight 
irritation  there.  In  some  instances  the  disease  may  occur  as  an  epi- 
demic, though  here,  probably,  there  is  some  specific  cause  at  work, 
and  the  condition  a  form  of  specific  infectious  disease  rather  than  a 
purely  local  inflammation.  In  the  exanthematous  fevers,  such  as 
small-pox,  scarlatina,  rubeola,  etc.,  an  exanthematous  inflammation 
of  the  pharynx  attends  as  a  part  of  the  febrile  condition.  Erysipela- 
tous  inflammation  of  the  pharynx  may  originate  as  an  extension  of 
facial  erysipelas  through  the  auditory  meatus  or  nasal  duct,  or  it 
may  arise  independently,  from  direct  erysipelatous  infection  of  the 
part. 

Symptoms. — Pain  in  the  pharynx,  with  a  disagreeable  sensation 
of  dryness,  irritation,  fullness  and  difficulty  of  swallowing,  mark  the 
outset  of  the  disease,  these  symptoms  coming  on  a  few  hours  after 
exposure  to  draughts  or  dampness.  The  patient  frequently  attempts 
to  clear  the  throat  by  hawking  and  swallowing.  The  voice  is  muffled 
and  there  is  a  short,  dry  cough.  There  may  be  slight  febrile  dis- 
turbance, especially  in  children.  The  extent  and  severity  of  the  in- 
flammatory action  is  best  determined  by  inspection  of  the  throat. 
Sometimes  the  inflammatory  blush  (redness)  extends  forward,  involv- 
ing the  palate  and  pillars  of  the  fauces.  The  posterior  uares  are 
often  involved,  the  patient  complaining  of  burning  there  and  making 
frequent  efforts  to  clear  the  passages  of  screatus.  Headache  is  now 
a  frequent  symptom,  this  continuing  for  several  days  until  the  acute 
symptoms  have  subsided.  The  uvula  is  often  involved  and  it  may  be 
cedematous  and  elongated. 

Acute  pharygitis  is  occasionally  erysipelatous  in  character,  and 
then  there  is  a  peculiar  bright  redness  to  the  affected  part,  the 
inflammation  extending  rapidly  and  widely,  oedema  and  puffing  of 
the  inflamed  area  being  marked  and  constitutional  symptoms  severe. 

Treatment. — Ordinary  cases  of  acute  pharyngitis  recover  rap- 
idly on  the  following  prescription:  $  Green-root  tinct.  of  phyto- 
lacca  31,  Lloyd's  or  other  reliable  fluid  ex-tract  of  aconite  gtt.  v— x, 
water  ziv.  Mix,  and  order  a  teaspoonful  every  hour.  Where  the  in- 
flammation is  severe  and  stubborn,  the  addition  of  <;i  of  jaborandi  to 
the  preceding  prescription  will  be  of  much  service,  and  often  much 
advantage  will  attend  the  use  of  a  gargle  of  one  part  of  echinacea  to 
four  or  five  of  water,  its  use  being  repeated  frequently — every  half- 
or  quarter-hour.  In  erysipelatous  pharyngitis  the  internal  use  of 
echinacea  is  essential,  two  or  three  drachms  of  the  specific  medicine 
being  added  to  half  a  glass  of  water  and  a  teaspoonful  ordered  every 
hour.  Jaboraudi  does  well  here  in  combination  with  the  echinacea, 
in  about  the  quantity  already  indicated.  Erysipelatous  pharyngitis 
with  puffiness  of  the  tissue  especially  indicates  minute  doses  of  apis. 


360  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

When  the  vault  of  the  pharynx  and  the  posterior  iiares  are  severe- 
ly affected,  the  following  prescription  may  answer  better  than  the 
treatment  first  suggested:  H  Specific  apocynum  caimabium  3!,  aco- 
nite gtt.  v-x,  water,  ?iv.  M.  Sig.  Take  a  spoonful  every  hour.  lu 
other  cases  of  this  kind  sambucus  canadensis  may  be  used  in  place  of 
the  apocynum,  in  the  same  quantity. 

Cold  water  packs  are  the  best  local  application  in  this  affection, 
though  some  prefer  heating  fomentations.  A  small  towel  may  be 
wrung  out  of  cold  water  and  folded  to  the  appropriate  size,  and  the 
throat  bandaged  with  it,  the  application  being  renewed  every  three 
or  four  hours. 

In  connection  with  the  treatment  the  patient  should  be  enjoined 
to  avoid  empty  swallowing,  hawking  and  attempts  at  forcible  removal 
of  screatus  from  the  posterior  nares. 

Should  the  uvula  become  elongated  and  oedematous  during  the 
course  of  acute  pharyngitis  it  should  not  be  excised  at  that  time,  as 
the  operation  would  be  liable  to  aggravate  the  local  difficulty  and 
serious  results  might  happen,  especially  in  erysipelatous  pharyngitis. 

PHLEGMONOUS  PHARYNGITIS. 

RETRO- PHABYNGEAL  abscess,  attended  by  severe  inflammatory  ac- 
tion, occasionally  occurs.  It  may  be  due  to  local  injury,  such  as  the 
irritating  influence  of  hot  food  or  penetration  by  spiculse  of  bone, 
though  it  usually  depends  upon  caries  of  the  cervical  vertebrae.  The 
inflammatory  action  may  be  treated  by  phytolaccca  and  aconite,  as  in 
simple  acute  pharyngitis,  pus  being  evacuated  early.  Silica  3x 
should  then  be  thought  of. 

GANGRENOUS  PHARYNGITIS. 

THIS  may  occur  in  connection  with  diphtheria,  small-pox  or  other 
infectious  disease.  In  addition  to  the  gangrenous  local  condition, 
there  are  usually  typhoid  symptoms  and  profound  prostration,  with, 
in  many  cases,  fatal  results.  Echinacea,  lacJiesis,  baptisia  and  other 
remedies  of  their  class  should  be  thought  of  early.  Frequent  spray- 
ing with  diluted  echinacea  may  accompany  its  internal  use. 

CHRONIC    PHARYNGITIS. 

Synynoms. — Pharyngeal    Catarrh;    Clergyman's    Sore    Throat; 
Pharyngitis  Sicca. 

Etiology. — This  condition  may  be  developed  from  repeated  at- 
tacks of  acute  pharyngitis,  or  it  may  rise  imperceptibly  from  sub- 
acute  inflammation  of  the  part.  It  is  common  in  public  speakers, 
auctioneers  and  hucksters,  who  overstrain  the  voice.  Excessive 


DISEASES  OF  THE  PHARYNX.  361 

smokers  and  drinkers  are  also  specially  liable  to  suffer  with  it.  It 
may  be  brought  on  by  persistent  efforts  to  clear  the  throat  by  empty 
swallowing,  hawking,  removal  of  screatus  from  the  posterior  nares, 
and  such  causes. 

Pathology. — The  mucous  membrane  of  the  naso-pharynx  arid 
posterior  wall  of  the  pharynx  are  relaxed,  the  venules  are  dilated  and 
the  mucous  glands  are  each  surrounded  by  proliferation  of  lymph- 
tissue.  When  this  is  very  abundant,  the  functions  of  the  glands  are 
destroyed  and  the  mucous  membrane  becomes  dry  and  glistening, 
constituting  pharyngitis  sicca. 

Symptoms. — The  patient  may  not  manifest  much  discomfort, 
though  often  there  is  dryness  of  the  throat  on  awaking  in  the  morn- 
ing, with  sensation  as  of  a  foreign  body  in  the  part,  provoking  hawk- 
ing and  empty  swallowing.  The  mucous  membrane  of  the  posterior 
pharyngeal  wall  is  usually  dusky,  the  veins  are  enlarged  and  in  fol- 
licular  pharyngitis  there  are  raised  points  of  bright,  reddened  tissue 
distributed  upon  its  surface.  A  mass  of  tenacious  mucus  will  usu- 
ally be  found  adhering  to  the  posterior  pharyngeal  wall,  extending 
downward  from  behind  the  soft  palate.  If  destruction  of  the  mucous 
follicles  has  been  accomplished  the  surrounding  mucous  membrane 
will  be  found  dry  and  shining.  A  short,  dry  cough  indicates  more 
or  less  irritation  of  the  larynx.  In  many  cases  the  uvula  is  congested 
and  elongated  and  becomes  an  additional  cause  of  laryngeal  irrita- 
tion, cough  being  a  common  symptom, 

Treatment. — The  treatment  of  the  catarrhal  form  of  chronic 
pharyngitis  is  neither  difficult  nor  tedious.  Galvanism,  applied  to 
the  affected  part,  two  or  three  times  a  week  for  a  month  or  more, 
produces  excellent  results,  if  not  a  complete  cure.  Confirmation  of 
cure  is  but  a  question  of  time;  persevere  in  the  treatment  and  the 
cure  is  sure  to  follow,  if  the  patient  gives  the  part  rest  from  hawk- 
ing and  unnecessary  empty  swallowing.  An  electrode  may  be  im- 
provised writh  the  aid  of 
a  section  of  copper  wire, 
a  piece  of  rubber  tubing 

IMPROVISED  PHABYNGEAL  ELZCTBODE.  and  a  pledget  of    absorb- 

ent  cotton,  which  will  answer  the  purpose  admirably.  A  loop  is  bent 
upon  one  end  of  the  wire,  for  purpose  of  connection,  the  tubing  is 
then  drawn  on  so  as  to  leave  about  three-fourths  of  an  inch  of  the 
further  extremity  exposed,  and  this  is  turned  up  at  right  angles,  for 
the  attachment  of  the  absorbent  cotton,  which,  when  wetted  in  plain 
water,  constitutes  an  excellent  applicator.  When  in  use,  the  loop  is 
to  be  placed  and  held  in  contact  with  the  tip  of  a  conducting  cord 
attached  to  a  galvanic  battery,  while  the  patient  holds  a  moistened 
sponge  connected  with  the  opposite  pole  in  one  hand  (after  the  cot- 


362  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

ton-carrier  hag  been  placed  in  position  in  the  throat).  A  current  of 
three  or  four  milliamperes  (six  or  eight  four-ounce  carbon-zinc  cells 
in  active  condition)  should  be  used  in  this  case.  The  patient  may 
not  be  able  to  endure  the  electrode  in  the  throat  for  more  than  a 
few  seconds  at  a  time  as  it  is  liable  to  produce  retching,  but  the 
application  should  be  made  two  or  three  times  at  each  sitting  and  re- 
peated twice  a  week.  The  hooked  portion  of  the  applicator  should 
be  carried  up  behind  the  soft  palate  so  as  to  bring  the  current  in 
contact  with  that  part,  where  the  trouble  is  almost  always  most  se- 
vere. Sometimes  the  operator  may  advantageously  apply  the  wetted 
sponge  to  the  angle  of  the  jaw  on  each  side,  that  the  current  may  be 
sent  directly  through  the  wall  of  the  pharynx. 

The  pole  to  be  applied  must  be  selected  with  reference  to  the 
condition  of  the  part,  though  the  negative  will  usually  be  most  effec- 
tive. However,  if  there  is  great  relaxation  with  profuse  catarrhal 
discharge  or  if  there  is  marked  irritability,  the  positive  may  answer 
better. 

In  connection  with  this  treatment,  considerable  benefit  may  be 
derived  from  collinsortia,  penthorum  sedoides  or  cistus  canadensis.  Ten 
drops  of  specific  medicine  of  either  agent  may  be  administered  at  a 
dose  in  a  little  water  before  meals  and  at  bedtime.  Such  agents, 
assisted  by  sprays  and  gargles  of  different  kinds,  may  alone  accom- 
plish cures,  though  results  are  not  ordinarily  satisfactory, 

In  follicular  pharyngitis  and  in  other  forms  where  hypertrophic 
spots  are  apparent,  gcdvano-cautery  may  be  used  to  destroy  them,  ap- 
propriate medicines  being  taken,  meanwhile,  to  promote  a  healthy 
condition  of  the  mucous  membrane. 

In  pharyngitis  sicca  jaborandi  possesses  specific  properties.  Ten 
drops  of  the  specific  medicine  should  be  used  at  a  dose  persistently 
four  or  five  times  daily  for  months,  attention  being  paid  to  the  con- 
stitutional condition  of  the  patient  as  well.  Guaiacum  also  Dossesses 
considerable  virtue  here,  in  minute  doses. 

If  the  uvula  is  elongated  or  relaxed  it  should  be  caught  with  a 
rat-tooth  catch  forceps  at  the  tip,  drawn  slightly  forward  and  half  or 
more  of  its  length  snipped  off  with  scissors  curved  on  the  flat.  This 
will  ensure  the  permanent  removal  of  one  source  of  irritation. 

Arduous  use  of  the  voice  should  be  discontinued;  smokers  affected 
with  the  disease  should  abandon  the  habit,  and  those  addicted  to  al- 
coholism should  abstain  from  all  alcoholic  liquors. 

The  habit  of  wearing  a  cold  wet  pack  on  the  throat  at  night  is  an 
excellent  one. 

ULCERATION  OF  THE  PHARYNX. 

Etiology. — Ulcers  of  the  pharynx  may  depend  upon  a  number  of 
causes.  Among  them  may  be  named:  (1)  Those  which  arise  from 


DISEASES  OF  THE  PHARYNX.  363 

follicular  pharyngitis;  (2)  those  from  syphilis;  (3)  those  from  cancer; 
(4)  those  from  tuberculosis. 

Symptoms. — Follicular  ulceration  is  easily  detected.  The  raised, 
isolated  points  on  the  posterior  pharyngeal  wall,  one  or  more  of  them 
being  the  seat  of  superficial  ulceration  without  induration  or  ten- 
dency to  deep,  destructive  action,  distinguish  them  from  other  forms. 
They  should  be  treated  with  galvano-caidcry,  or  fuming  nitric  acid  ap- 
plied with  a  pine  stick. 

Syphilitic  ulceration  of  the  throat  is  more  chronic  and  less  painful, 
the  ulcers  of  secondary  syphilis  being  multiple,  while  those  of  ter- 
tiary syphilis  are  deeper  and  usually  single,  denoting  the  erosion  of 
a  gumma.  The  history  of  the  case  will  assist  the  practitioner  to  a 
clear  diagnosis  where  syphilitic  ulceration  is  present.  Galvanism  is 
the  proper  agent  for  the  successful  treatment  of  such  cases.  The 
negative  pole  is  applied  to  the  ulcer  or  ulcers  twice  a  week,  the  pa- 
tient holding  a  positive  sponge- electrode  in  the  hand.  To  assist  the 
local  agent  the  following  prescription  will  be  found  an  important 
aid:  R  Specific  corydalis  fss,  specific  berberis  (or  Parke,  Davis  & 
Co.'s  fluid  extract)  3!,  simple  elixir  ad  ?iv.  Sig.  Take  a  teaspoonful 
four  or  five  times  daily.  When  the  ulcers  are  tertiary  in  character, 
the  addition  of  iodide  of  potassium  to  this  prescription  may  occa- 
sionally be  desirable. 

It  may  be  difficult  to  always  distinguish  cancerous  ulceration  from 
that  of  syphilis,  though  it  is  to  be  remembered  that  the  ulceration  of 
cancer  is  usually  extremely  painful,  while  that  of  syphilis  is  compar- 
atively painless.  Cancerous  ulceration,  moreover,  is  steadily  pro- 
gressive, while  syphilitic  ulceration,  after  developing,  is  usually  sta- 
tionary. The  history  of  the  case  will  afford  additional  light  upon  the 
subject.  The  best  that  can  be  advised  for  cancerous  ulceration  of 
the  pharynx  is  treatment  to  relieve  the  pain.  Opiates  are  of  little 
value,  and  the  only  remedy  of  much  use  is  echinacea,  which  usually 
renders  the  condition  a  comparatively  painless  one,  while  the  patient 
retains  consciousness  and  the  use  of  his  mental  faculties  to  the  last. 
From  ten  to  twenty  drops  of  the  specific  medicine  may  be  adminis- 
tered at  a  dose  in  a  little  water  every  three  or  four  hours  during  the 
day.  The  local  application  of  grinclelia  robusta,  repeated  often,  is  to 
be  highly  commended  here.  R  Grindelia  robusta  -$n  to  aqua  siv.  It 
may  be  applied  with  a  spray  apparatus. 

Tuberculous  ulceration  occurs  in  some  cases  of  advanced  phthisis. 
The  ulcers  are  ragged  and  irregular,  with  ill-defined  edges  and  yel- 
lowish-gray bottoms,  and  are  intensely  painful.  The  general  condi- 
tion of  the  patient  and  the  history  of  the  case  will  suffice  for  a  diag- 
nosis. The  ulcers  should  be  frequently  sprayed  with  bovinine,  and  the 
same  agent  should  be  administered  internally  in  appropriate  doses. 


364  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

An  excellent  application  to  this  as  well  as  to  all  other  pharyngeal 
ulcers  will  be  found  in  Jiydrozone. 

LUDWIG'S  ANGINA. 

Synonyms. — Angina  Ludovici;  Cellulitis  of  the  Neck. 

Definition. — A  cellular  inflammation  of  the  tissues  of  the  neck 
encountered  during  medical  practice  as  a  complication  of  specific  in- 
fectious diseases,  especially  diphtheria  and  scarlatina. 

Etiology. — In  addition  to  the  infection  of  streptococci,  which 
originates  it  in  the  specific  fevers,  it  may  arise  as  a  result  of  trauma- 
tisni  and  may  even  occur  idiopathically.  In  every  case  it  is  even 
possibly  due,  eventually,  to  infection  from  streptococci. 

Symptoms. — Swelling  begins  about  the  submaxillary  gland  of 
one  side  at  first,  but  it  soon  becomes  general,  septicaemia,  oedema, 
glottidis,  secondary  pneumonia  or  gangrene  of  the  affected  parts 
proving  fatal  in  many  cases  in  a  short  time.  Termination  by  abscess 
is  the  most  desirable  end  to  be  expected. 

Treatment. — Echinacea,  lachesis  and  baptlsia,  combined  with 
prompt  surgical  interference  whenever  practicable. 

IV.  DISEASES  OF  THE  TONSILS. 

FOLLICDLAR    TONSILLITIS. 

Synonym. — Lacunar  Tonsillitis. 

Definition. — A  form  of  acute  tonsillitis  in  which  the  inflamma- 
tion involves  the  mucous  membrane  covering  the  glands  and  lining 
the  crypts  or  follicles  of  the  tonsils. 

Etiology. — Children  and  youug  adults  are  more  liable  to  be  af- 
fected by  this  disease  than  elderly  persons,  and  it  is  rare  during  in- 
fantile life.  Exposure  to  wet  and  cold  is  the  common  cause,  though 
bad  hygienic  surroundings,  such  as  defective  drainage,  malaria,  sewer- 
gas,  etc.,  are  believed  to  exert  some  influence  in  its  causation.  Some 
believe  that  there  is  a  relationship  between  this  disease  and  rheuma- 
tism— that  the  two  are  liable  to  coexist — and  some  even  claim  that 
follicular  tonsillitis  is  a  phase  of  rheumatism  which  affects  children. 
While  these  are  facts  which  lend  support  to  the  theory  that  rheuma- 
tism is  allied,  etiologically,  to  catarrhal  disturbance,  it  is  not  proba- 
ble that  tonsillitis  sustains  any  more  relation  to  it  than  other  acute 
catarrhal  affections. 

Pathology. — The  mucous  membrane  lining  the  crypts  is  most 
severely  inflamed,  though  that  covering  the  external  portion  of  the 
tonsil  is  also  affected.  The  follicles  exude  a  whitish  material,  con- 
sisting of  pus-cells,  epithelial  cells,  bacteria  and  mucus,  which  appears 


DISEASES  OF  THE  TONSILS.  365 

at  the  mouths  of  the  lacunae  as  circumscribed  white  spots  resembling 
the  exudation  of  diphtheria  in  general  appearance  but  differing  from 
it  materially  iu  true  character,  as  it  lacks  the  fibrin  found  in  the  ex- 
udation of  that  disease. 

Symptoms. — The  constitutional  symptoms  of  follicular  tonsillitis 
are  often  out  of  proportion  to  the  local  trouble.  There  is  usually  an 
initiatory  chill  with  rapid  pulse,  the  temperature  rising  as  high  as 
103°  or  104°  F.  and  sometimes  higher.  Muscular  pain  is  a  usual 
symptom  in  greater  or  less  degree  and  is  often  marked.  There  is 
severe  aching  in  the  muscles  of  the  neck  and  head,  which  may  extend 
along  the  back,  the  muscular  pain  assuming  the  proportions  of  mus- 
cular rheumatism  and  demanding  special  therapeutic  attention.  The 
throat  is  now  stiffened  and  swollen,  the  tonsils  enlarged  and  their  sur- 
faces dotted  with  spots  of  creamy-white  exudate  occupying  the  mouths 
of  the  crypts,  and  they  may  be  so  abundant  as  to  coalesce  in  some 
places,  though  this  condition  is  not  common.  The  cervical  lymphat- 
ics are  slightly  though  not  markedly  enlarged.  Respiration  is  more 
or  less  impeded,  the  breath  is  foul  and  swallowing  difficult.  The 
tongue  is  loaded  with  a  pasty-white  fur,  the  bowels  are  constipated 
and  the  urine  is  scanty  and  throws  down  urates.  Prostration  is  a 
marked  symptom  at  first,  though  with  proper  treatment  the  weakness 
abates  within  three  or  four  days,  the  swelling  subsides  and  the  fever 
and  muscular  pain  disappear.  Recurring  attacks,  however,  are  not 
uncommon  upon  slight  exposure. 

Diagnosis. — The  diagnosis  between  follicular  tonsillitis  and  mild 
cases  of  diphtheria  is  not  always  an  easy  matter.  Diphtheria  may 
begin  in  the  follicles  of  the  tonsil  and  the  first  appearance  of  the  part 
may  be  that  of  lacunar  tonsillitis.  It  is  to  be  remembered,  however, 
that  the  exudate  of  diphtheria  spreads  with  greater  .or  less  rapidity 
and  soon  creeps  along  the  tonsillar  surface  to  the  pharynx  and  spreads 
upon  its  walls.  It  is  ashen-gray  in  color,  in  contrast  with  the  creamy- 
white  color  of  the  exudation  of  tonsillitis.  The  enlargement  of  the 
cervical  glands  is  also  much  more  marked  in  diphtheria,  while  there 
is  hardly  ever  so  much  elevation  of  temperature  as  there  is  in  tonsil- 
litis. Bacteriologists  presume  to  differentiate  with  the  microscope, 
and  assert  that  the  presence  of  the  Klebs-Loffler  bacillus  is  diagnos- 
tic of  diphtheria,  but  my  own  experience  has  shown  me  that  grave 
errors  arise  when  this  is  made  the  principal  means  of  diagnosis. 

Prognosis. — Follicular  tonsillitis  is  usually  readily  controlled  by 
Eclectic  treatment.  Even  a  few  hours  of  proper  medication  find  the 
patient  much  more  comfortable  and  a  couple  of  days  suffices  to  con- 
trol nearly  all  unpleasantness,  only  slight  local  discomfort  remaining. 

Treatment. — Aconite  and  phytolacca  will  soon  relieve  the  urgent 
symptoms.  The  following  prescription,  for  an  adult,  is  the  proper 


366  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

thing:  U  Green-root  tincture  (or  specific)  phytolacca  31,  Lloyd's 
aconite  gtt.  v-x,  aqua  ad  fiv.  S.  Take  a  teaspoonful  every  hour. 
This  will  soon  control  the  fever  and  assuage  the  local  irritation,  and 
the  principal  requirement  then  is  to  relieve  the  muscular  pain.  This 
is  readily  accomplished  with,  macrotys  or  rhamnus  cali/ornica.  I  pre- 
fer to  use  these  agents  in  the  form  of  decoction,  in  half  or  full  wine- 
glass doses,  macrotys  being  preferable  where  the  bowels  are  sensitive 
to  the  cathartic  action  of  the  rhamnus.  One  of  these  agents  should 
be  administered  steadily  until  the  muscular  pain  has  subsided. 
Where  the  rhamnus  causes  catharsis  or  the  cimicifuga  causes  head- 
ache the  dose  should  be  considerably  lessened. 

Periodicity  is  a  common  attendant  of  follicular  tonsillitis  in  mala- 
rious districts,  and  satisfactory  treatment  demands  that  this  element 
shall  be  properly  managed.  The  antiperiodic  action  of  quinia  sul- 
phas may  here  be  sought  by  the  common  method,  or  three-grain 
doses  of  arseniate  of  quinia  3x,  repeated  every  four  hours  for  two  or 
three  days,  may  be  used  instead.  When  the  patient  is  robust  and  the 
system  is  in  a  proper  condition  for  the  administration  of  quiiiia,  it 
will  produce  the  most  prompt  results.  The  arseniate  is  more  pleas- 
ant, but  requires  a  longer  time  to  produce  the  effect. 

The  compound  tincture  of  guaiacum  or  powdered  gum  guaiac  is 
an  excellent  remedy  in  this  disease,  though  with  aconite  and  phyto- 
lacca  we  will  hardly  care  to  make  use  of  it,  as  the  combination  is  un- 
equalled in  pleasantness  and  efficiency  for  its  effect  on  tonsillar  in- 
flammation of  this  character.  Where  the  patient  seems  predisposed 
to  frequent  recurrences  of  the  disease  the  protracted  use  of  baryta 
carb.  3x  will  assist  in  fortifying  the  parts  against  later  invasion. 

Local  applications  are  not  of  much  use  except  for  their  mental 
influence,  though  sometimes  this  is  not  to  be  neglected.  Thus,  vine- 
gar packs  may  be  employed  or  even  tepid-water  packs.  Hot  appli- 
cations might  favor  suppurative  action,  and  are  to  be  avoided. 

PEBITONSILLAB  ABSCESS. 

Synonyms — Quinsy;  Amygdalitis. 

Definition. — An  inflammation  of  the  connective  tissue  external 
to  the  tonsil. 

Etiology. — Any  of  the  causes  of  follicular  tonsillitis  may  give 
rise  to  peritousillar  abscess,  though  it  may  arise  from  infection  orig- 
inated by  that  disease.  When  quinsy  has  once  occurred,  the  subject 
is  especially  prone  to  later  attacks  upon  slight  provocation,  a  perma- 
nent susceptibility  seeming  to  remain  for  years. 

Pathology. — Suppurative  inflammation  occurs  in  the  connective 
tissue  surrounding  the  tonsil,  the  upper  portion  being  usually  affect- 


DISEASES  OF  THE  TONSILS.  367 

ed,  as  the  dense  structure  at  the  lower  anterior  part  of  the  gland  is 
more  resisting.  The  abscess  usually  extends  upwards  between  the 
pillars  of  the  fauces  and  sometimes  backward  and  downward  along 
the  posterior  pillar. 

Symptoms. — These  are  usually  severe,  the  affected  part  being 
swollen  and  sensitive,  that  side  of  the  neck  being  stiffened  and  en- 
larged externally.  The  jaws  soon  become  so  swollen  as  to  prevent 
opening  of  the  mouth,  and  deglutition  is  extremely  difficult  and  pain- 
ful. The  voice  becomes  muffled  and  nasal,  and  complete  inability  to 
swallow  often  results  from  the  extensive  tumefaction  about  the  fauces. 
Throbbing  in  the  affected  part  begins  early,  the  tensive  pain  being 
varied  by  alternate  dartings  in  the  middle  ear.  Chilliness  at  inter- 
vals heralds  the  advent  oE  suppuration,  which  begins  within  two  or 
three  days  after  the  initiation  of  the  active  symptoms;  and  the  pa- 
tient is  now  only  able  to  open  the  jaws  sufficiently  to  protrude  the 
tongue  with  great  difficulty.  If  examined  early  the  tonsil  will  pre- 
sent a  lateral  tumefaction,  which  crowds  the  soft  palate  upward  and 
and  the  tongue  downward  on  the  affected  side  and  bulges  into  the 
opening  of  the  fauces,  sometimes  nearly  closing  it,  the  mucous  mem- 
brane presenting  an  angry,  reddened  appearance.  As  suppuration 
proceeds  a  prominent  bulging  point  may  be  distinguished  just  beneath 
the  soft  palate  of  the  affected  side,  indicating  the  near  approach  of 
pus  to  the  surface. 

The  tongue  is  usually  heavily  coated  with  a  pasty-white,  offensive 
fur,  the  breath  is  foetid,  and  constant  accumulation  of  tenacious  mucus 
in  the  throat  gives  rise  to  frequent  hawking  and  other  efforts  to  clear 
the  passage.  There  is  usually  elevation  of  temperature,  the  ther- 
mometer often  indicating  from  102°  to  104°  F.  The  bowels  are  con- 
stipated, the  urine  scanty  and  high  colored,  the  skin  dry  and  husky 
and  the  patient  is  restless  and  uneasy,  his  sleep  being  noisy  and 
stertorous. 

Diagnosis. — Eetro-pharyngeal  abscess  might  be  mistaken  for 
quinsy,  though  palpation  of  the  affected  side  at  the  angle  of  the  jaw 
and  examination  with  the  finger  within  the  throat  will  remove  all 
doubt. 

Prognosis. — There  is  some  danger  of  escape  of  pus  into  the 
larynx  at  the  moment  of  discharge,  especially  if  it  occurs  with  the 
patient  in  the  recumbent  position.  CEclematous  laryngitis  is  among 
the  possible  complications,  and  this  may  render  asphyxia  imminent. 
However,  with  good  treatment  a  favorable  termination  may  usually 
be  anticipated. 

Treatment. — An  excellent  prophylactic,  where  the  quinsy-habit 
has  become  established,  is  the  protracted  use  of  baryta,  carb.  3x,  and 
this  is  especially  commendable  upon  the  first  appearance  of  the 


368  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

symptoms  of  an  attack.  The  early  use  of  potassium  chloride  3x  is 
also  commendable,  as,  if  begun  early,  it  promises  to  arrest  the  forma- 
tion of  pus  and  abort  the  disease.  When  follicular  tonsillitis  occurs 
coincidently,  as  is  sometimes  the  case,  phytolacca  and  aconite  may  be 
alternated  with  one  of  these  remedies.  Two  grains  of  the  3x  tritura- 
tion  of  baryta  carb.  may  be  administered  every  two  hours  when  used 
to  abort  the  disease,  or  every  three  or  four  when  used  to  fortify  the 
tonsil  against  future  attacks.  If  potassium  chloride  is  to  be  used 
dissolve  five  grains  of  the  3x  trituration  in  half  a  common  tumbler  of 
water  and  give  a  teaspoonful  every  one  or  two  hours. 

Early  puncture  with  an  aseptic  bistoury  is  the  best  treatment 
after  suppuration  has  been  established.  Even  if  pus  be  not  already 
formed  early  evacuation  of  blood  relieves  painful  tumefaction  and 

the  incision  facilitates  prompt  escape  of  the 
earliest  formation  of  purulent  material.     The 
puncture  should  be  made  near  the  upper  por- 
tion of  the  tonsil,  just  below  the  soft  palate, 
in  a  horizontal    direction,  nearly    backward, 
rather  toward  the  median  line  of  the  throat. 
ABSCESS.        In  the  absence  of  a  tonsil  bistoury  a  common 
P,  point  for  puncture.         straight  bistoury  may  be  guarded,  except  at 
the  point,  with  a  wrapping  of  linen  or  cotton  cloth,  and  serve  an 
equally  good  purpose. 

The  patient  may  be  nourished,  in  event  of  inability  to  swallow, 
by  injecting  milk  or  other  liquid  food  into  the  oesophagus  with  a 
Davidson  syringe  through  a  gum-elastic  catheter. 

CHRONIC  TONSILLITIS. 

Synonym. — Hypertrophy  of  the  Tonsils. 

Definition. — Chronic  enlargement  of  the  tonsils,  usually  occur- 
ring in  children. 

Etiology. — Chronic  tonsillitis  may  arise  from  repeated  attacks 
of  follicular  tonsillitis  or  may  come  on  insidiously.  Members  of  cer- 
tain families  are  especially  prone  to  its  development,  those  of  lym- 
phatic temperament  being  probably  most  liable.  Children  of  syphi- 
litic, tubercular  or  rheumatic  history  are  often  subjects  of  chronic 
tonsillitis.  It  is  also  liable  to  follow  attacks  of  scarlatina,  diphtheria, 
rubella,  measles  and  other  severe  infectious  diseases,  especially  those 
which  are  attended  by  faucial  irritation.  It  is  most  common  between 
the  ages  of  three  and  five,  though  older  children  may  be  affected  by 
it.  After  the  age  of  fifteen  there  is  a  general  tendency  for  the  glands 
to  undergo  atrophy,  the  process  being  slow,  however,  and  often  con- 
tinuing to  the  thirtieth  year. 


DISEASES  OF  THE  TONSILS.  369 

Pathology. — All  the  tissues  of  the  tonsils  increase  in  size,  the 
number  of  lymphoid  cells  being  especially  augmented.  The  follicles 
become  deepened  and  dilated,  their  orifices  being  visible  to  the  naked 
eye  upon  superficial  inspection,  the  gaping  openings  often  disclosing 
the  presence  of  a  yellowish-white,  offensive,  curdy  material  within. 
The  lax  structure  permits  of  the  rapid  growth  of  adventitious  tissue 
in  the  tonsils,  and  rapid  enlargement  usually  results  when  the  hyper- 
trophic  processes  begin,  the  fauces  being  soon  blocked  by  the  pro- 
truding organs. 

Symptoms. — A  subject  of  hypertrophic  tonsillitis  is  constantly 
annoyed  with  a  sensation  as  of  a  foreign  body  in  the  throat.  The 
voice  is  muffled  and  husky  and  deglutition  is  impaired — though  not 
severely,  except  when  an  attack  of  acute  tonsillitis  occurs  in  connec- 
tion with  it,  which,  however,  is  often  the  case.  Respiration  is  through 
the  mouth,  and  sleep  is  usually  characterized  by  chokings  and  start- 
ings — which  are  many  times  alarming  to  parents,  strangulation  being 
frequently  suggested  at  night,  though  not  at  all  imminent.  Hearing 
is  often  impaired  from  tumefaction  about  the  orifices  of  the  Eustach- 
ian  tubes.  Upon  inspection  the  glands  will  be  found  dusky  and  swol- 
len, obstructing  the  fauces  to  greater  or  less  extent  and  presenting 
the  gaping  orifices  with  curdy  contents  as  described  under  pathology, 
the  breath  being  foetid  and  offensive. 

The  habit  of  mouth-breathing  entails  more  or  less  pharyngeal  and 
laryngeal  irritation,  manifested  by  hawking,  empty  swallowing  and 
hacking  cough.  Obstructed  respiration  and  resultant  defective  oxy- 
genation  of  the  blood  are  liable  to  terminate  in  deterioration  of  the 
general  health.  Long-continued  post-nasal  obstruction  may  give  rise 
to  a  stupid,  dejected  cast  of  countenance  so  peculiar  to  this  form  of 
tonsillitis,  and  the  conformation  of  the  thorax  may  finally  become 
altered,  the  chest  being  flattened  at  the  sides  and  bulged  forward  at 
the  sternum. 

Diagnosis. — Malignant  disease  of  the  part  might  be  mistaken 
during  its  early  stage  for  chronic  tonsillitis,  though  the  bright  red 
color,  severe  pain  and  lateral  character  of  malignant  disease  (one 
side  being  affected  rather  than  both)  would  afford  clearly  defined 
diagnostic  differentiation.  As  the  disease  advanced  to  a  later  stage 
there  should  be  no  chance  for  confusion. 

Prognosis. — As  the  hypertrophy  continues  there  is  increased 
danger  of  permanent  damage  to  the  voice  as  well  as  to  the  general 
health.  Even  though  atrophy  may  be  expected  to  begin  at  puberty, 
it  is  not  advisable  to  neglect  the  present  condition.  There  is  in- 
creased liability  to  such  infectious  diseases  as  diphtheria,  scarlatina, 
etc.,  when  the  follicles  are  enlarged,  and  treatment  for  a  radical  cure 
is  therefore  additionally  important. 


•25 


370  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

Treatment. — Certain  remedies  influence  the  tonsils  and  reduce 
enlargement  in  hypertrophied  conditions.  Baryta  carb.  is  excellent 
for  this  purpose,  two  or  three  grains  of  the  3x  trituration  three  or 
four  times  daily  answering  a  good  purpose  when  persevered  in  for 
several  months  at  a  time.  The  iodide  of  barium  is  also  an  excellent 
remedy  employed  in  the  same  manner.  A  reliable  auxiliary  is  the 
galvanic  current,  which  may  be  applied  twice  weekly  by  holding  a 
positive  electrode  against  the  tonsil  in  the  throat  and  the  negative 
sponge  upon  the  outer  surface  over  the  affected  region.  The  patient 
will  be  able  to  bear  the  current  only  a  second  or  two  at  a  time,  but 
it  may  be  repeated  two  or  three  times  at  each  sitting.  Interstitial 
injections  of  ergot,  thuja,  and  iodine  into  the  tonsils  have  been  success- 
fully used  by  some.  Perhaps  the  local  application  of  galvano-cautery 
may  prove  more  reliable  still,  deep  cauterization  being  followed  by 
cicatrization  and  contraction  of  the  part.  When  such  measures  fail, 
amputation  of  the  organs  may  be  in  order,  the  operation  being  simple 
and  of  little  danger,  while  loss  of  the  tonsils  involves  no  serious  re- 
sults to  the  general  system.  A  small  volsellum  forceps  may  be  used 
to  steady  the  diseased  part  while  a  strong  scissors  (curved  on  the 
flat)  is  employed  to  excise  it.  Or,  a  tonsil  bistoury  may  be  used  in- 
stead. The  Matthieu  tonsillotome  is  an  excellent  instrument  for  re- 
moval of  the  tonsil,  when  intelligently  employed.  The  operation  is 
so  simple  that  the  ordinary  practitioner  need  not  hesitate  to  attempt 
it,  little  hemorrhage  following,  though  in  small  children  anaesthe- 
sia may  be  necessary. 

Adenoid  growths  upon  the  vault  of  the  pharynx  (the  third  tonsil) 
are  sometimes  complicated  with  chronic  tonsillitis  and  require  re- 
moval as  well  as  the  tonsils.  A  special  cutting  forceps  is  manufac- 
tured for  this  purpose. 

Dr.  H.  W.  Kendall,  of  Quincy,  111.,  describes  a  method  which  he 
has  used  with  advantage  for  ten  years:  "We  have  an  efficient  cauter- 
ant  and  at  the  same  time  an  antiseptic  and  alterant  in  pure  hydro- 
chloric acid,  which  is  always  friendly  to  human  flesh.  This  is  the 
agent  that  I  have  found  so  efficient  in  reducing  enlarged  glands  in  all 
parts  of  the  body,  but  the  method  of  using  it  is  the  particular  point 
that  I  wish  to  present  in  this  short  paper.  My  method  is  the  use  of 
capillary  glass  tubes  (Bohemian  or  Whitall  &  Tatum's  glass)  one- 
eighth  of  an  inch  calibre  heated  in  a  Bunsen  flame  and  drawn  to  a 
point,  the  shaft  of  the  drawn  part  two  inches  long,  with  calibre  one- 
sixty-fourth  of  an  inch,  broken  off  and  fire  polished.  Now,  if  the 
shaft  of  the  tube  is  five  inches  long  the  drawn  part  will  hold,  after 
dipping  in  the  fluid,  one  minim ;  if  the  larger  shaft  is  increased  in 
length  it  will  hold  more.  When  the  point  of  this  tube  touches  any 


DISEASES  OF  THE  (ESOPHAGUS.  371 

substance  it  will  deposit  a  fraction  of  the  drop;  by  long  contact  it  will 
deposit  all  that  it  contains. 

"I  dip  these  tubes  into  pure  fuming  hydrochloric  acid  and  push 
them  into  the  excretory  ducts  of  the  glands,  three  in  each  gland  at 
each  sitting  twice  a  week.  This  operation  is  painless  and  produces 
no  inflammation  or  swelling.  Five  or  six  applications  are  sufficient 
for  moderately  enlarged  glands." 

V.  DISEASES  OF  THE  (ESOPHAGUS. 

CESOPHAGITIS. 

Synonym. — Inflammatory  Dysphagia. 

Definition. — A  catarrhal  inflammation  of  a  part  or  the  whole  of 
the  mucous  membrane  of  the  oesophagus. 

Etiology. — Acute  inflammation  of  the  oesophagus  is  usually  due 
to  the  action  of  acrid  fluids  or  solids  in  their  passage  to  the  stomach. 
The  incautious  swallowing  of  scalding  fluids,  such  as  hot  chocolate, 
coffee,  or  of  hot  food,  occasionally  causes  it.  Children  sometimes 
swallow  lye  or  carbolic  acid,  or  the  latter  substance  is  taken  with 
suicidal  intent.  The  accidental  lodgment  of  spiculae  of  bone,  arti- 
ficial teeth  or  other  foreign  bodies  in  the  oesophagus,  sometimes  re- 
sults in  inflammation  of  acute  character,  which  is  followed  by  long- 
continued  subacute  or  chronic  inflammation.  The  excessive  use  of 
alcohol,  extension  of  pharyngitis  or  other  inflammation  of  the  throat 
to  the  oesophagus,  tuberculosis  and  other  exciting  and  predisposing 
causes  might  be  named.  Chronic  cesophagitis  may  follow  an  acute 
attack,  be  developed  from  a  tuberculous  or  syphilitic  condition  or 
be  due  to  the  irritation  of  a  foreign  body  lodged  along  the  tube. 
Diphtheritic  infection,  scarlatina,  cholera,  pyaemia,  septicaemia  or 
other  infectious  diseases  may  give  rise  to  membranous  cesophagitis. 

Pathology. — In  acute  cesophagitis  the  mucous  membrane  is  high- 
ly reddened  and  covered  with  a  layer  of  muco-pus  and  detached  epi- 
thelium, and  the  tissues  are  swollen  and  softened.  In  the  chronic 
form  the  mucous  membrane  is  darkened  to  a  slaty-blue  color,  the 
submucous  tissue  is  swollen  and  the  surface  is  covered  with  a  thick, 
tenacious  mixture  of  mucus  and  pus.  The  cesophageal  walls  gener- 
ally are  thickened,  arid  a  part  or  the  whole  of  the  tube  above  the 
location  of  an  ulcer,  which  will  mark  a  narrowing,  will  be  dilated  or 
there  may  be  several  constrictions  and  dilations.  Sometimes  exten- 
sive diverticula  are  formed  and  there  may  be  hernia  of  the  mucous 
membrane  through  the  muscular  wall,  with  final  perforation.  The 
ulceration  usually  occurs  at  the  seat  of  most  prominent  irritation. 


372  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

In  membranous  inflammation  the  morbid  changes  common  to  snch 
inflammation  upon  other  mucous  surfaces  will  appear. 

Symptoms. — In  acute  cesophagitis  burning  aud  gnawing  sensa- 
tions are  experienced  along  the  oesophagus,  behind  the  sternum, 
through  the  mediastinum  and  between  the  shoulders,  aggravated  by 
attempts  to  swallow  even  the  most  bland  liquids.  Extreme  thirst, 
great  depression  and  anxiety,  attended  by  slight  febrile  disturbance, 
are  present  in  the  acute  form.  In  chronic  oesophagitis  there  is  not 
much  pain  except  when  solids  are  swallowed,  though  if  ulceration 
exist  there  is  occasionally  vomiting  of  vicid  mucus  mixed  with  pus 
and  tinged  with  blood. 

Diagnosis. — Knowledge  of  the  provoking  cause  will  enable  the 
practitioner  in  acute  cases  to  arrive  at  a  correct  diagnosis.  Chronic 
oesophagitis  may  be  confounded  with  cancer,  but  here  the  severity 
of  the  pain,  which  is  severe  when  the  part  is  at  rest,  the  rapid  prog- 
ress of  the  symptoms  and  the  marked  cachexia,  will  render  the  diag- 
nosis clear. 

Prognosis. — In  acute  cesophagitis  the  damage  to  the  stomach 
and  other  associate  organs  should  be  taken  into  consideration  in  sum- 
ming up  the  probable  outcome.  In  croupous  oesophagitis  the  sys- 
temic condition  of  the  patient — the  severity  of  the  attending  case — 
will  determine,  more  than  the  local  condition,  the  probable  result. 
Chronic  and  subacute  cesophagitis,  where  deep-seated  stricture  is 
not  present,  are  amenable  to  curative  treatment. 

Treatment. — Where  cesophagitis  is  due  to  the  presence  of  for- 
eign bodies  in  the  oesophagus  their  removal  is  the  first  matter  to  be 
considered.  Inflammation  of  acute  character  should  be  treated  with 
veratrum  or  jaborandi  in  ordinary  sedative  doses.  EcJtinacea  may  be 

advantageously  com- 
bined with  either  or 
both  these  agents. 
Bichromate  of  potas- 
sium, in  the  2x  or  3x 
trituration,  acts  well 
'in  subacute  inflam- 
mation, and  la^hesis 
or  wq/a,  in  homeo- 
pathic  attenuations,  may  relieve  the  burning,  stabbing  pain.  After 
the  acute  symptoms  have  subsided  a  flexible  galvanic  electrode,  con- 
sisting of  an  elongated  shaft  of  spirally  coiled  brass  spring-wire 
(eighteen  or  twenty  inches  in  length)  covered  and  insulated  with  a 
section  of  rubber  tubing,  having  a  bulb-shaped  nickel-  or  silver- 
plated  metal  terminal  at  one  end  and  a  screw  clamp  attachment  at 
the  other,  connected  with  the  negative  cord,  may  be  passed  down- 


DISEASES  OF  THE  (ESOPHAGUS.  373 

ward  and  upward  along  the  oesophagus  twice  a  week  (two  or  three 
times)  with  a  current  of  from  five  to  ten  milliamperes  (or  eight  to 
sixteen  cells  of  an  ordinary  portable  carbon-zinc  battery).  This  is 
an  excellent  means  of  permanently  relieving  the  irritation  and  excori- 
ation. The  patient  should  take  the  positive  pole,  consisting  of  a 
wetted  sponge,  in  the  hand  only  after  the  bulb  has  passed  into  the 
O3sophagus,  as  unpleasant  shock  is  thus  averted. 

A  liquid  diet  should  be  used,  and  movement  of  the  part  avoided 
so  far  as  possible. 

OBSTRUCTION  or  THE  (ESOPHAGUS. 

Etiology. — This  condition  may  arise  from  a  variety  of  causes, 
which  may  be  arranged  under  the  following  heads:  (1)  Those  which 
are  due  to  organic  changes  in  the  walls  of  the  O3sophagus  from 
cancerous  infiltration;  hypertrophy  of  the  coats  generally  from  in- 
flammatory action,  the  submucous  coat  being  generally  involved; 
fibroid  changes  due  to  chronic  inflammation;  localized  thickening 
due  to  cicatrization  after  wounds,  lesions  and  ulcers;  syphilitic  dis- 
ease. (2)  External  pressure  from  various  causes,  such  as  broncho- 
cele;  enlargement  of  the  cervical  or  thoracic  lymphatics;  cancerous 
or  fibroid  tumors;  aneurisms;  abscesses;  great  tension  of  the  peri- 
cardium with  fluids.  (3)  Growths  within  the  O3sophagus,  such  as 
fibroid  tumors,  etc. 

Pathology, — Obstruction  at  any  point  finally  gives  rise  to  dilata- 
tion and  hypertrophy  of  the  oesophagus  above,  accumulation  of  food 
tending  to  distend  the  walls  of  the  part,  while  the  necessary  resist- 
ance favors  thickening  of  the  muscular  structure.  Continued  disten- 
tion,  however,  may  result  in  rupture  of  the  muscular  wall  with  her- 
nia of  the  mucous  membrane;  or  ulceration  may  finally  occur  at  some 
point,  with  possible  perforation. 

Symptoms. — Difficulty  of  swallowing  is  the  most  prominent 
symptom,  pain  and  sensation  of  stoppage  occurring  when  the  food 
reaches  the  point  of  obstruction,  this  most  commonly  being  behind 
the  upper  portion  of  the  sternum.  The  disease  is  progressive,  the 
difficulty  of  swallowing  becoming  more  and  more  marked  until  it 
is  impossible  for  even  the  smallest  particle  of  solid  food  to  reach 
the  stomach.  Liquids  and  soft,  pulpy  food-substances  pass  the 
obstruction  best.  When  food  cannot  pass  it  is  soon  rejected,  either 
by  gradual  regurgitation  or  sudden  spasmodic  action;  or,  being 
retained  for  a  time,  it  is  discharged  in  large  quantities  of  alkaline, 
sodden  material,  mingled  with  mucus  and  pus  and,  perhaps,  tinged 
with  blood.  If  the  condition  be  due  to  cancerous  infiltration  severe 
pain  usually  attends,  both  during  the  taking  of  food  and  between 


374  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

times  as  well,  and  debility,  emaciation,  waxy  color  and  other  symp- 
toms of  cancerous  cachexia  develop.  In  ordinary  ulceration  there 
is  not  much  pain  except  during  efforts  at  deglutition,  and  not  even 
then  unless  the  ulcer  be  irritable.  Another  cause  of  emaciation  and 
debility  besides  that  of  cancer  may  be  that  of  starvation  from  inabil- 
ity to  swallow  sufficient  food  to  meet  the  demands  of  the  body.  If 
perforation  occur  sudden  collapse  or  symptoms  of  septicaemia  may 
follow. 

Treatment. — Soft  strictures — those  involving  only  the  mucous 
and  submucous  structures — may  be  benefited  if  not  wholly  relieved 
by  the  patient  use  of  graduated  dilators,  employed  at  intervals  and 
passed  cautiously  to  avoid  irritation.  In  the  beginning  anaesthesia 
may  be  employed  and  afterward  a  full  dose  of  bromide  of  potassium 
may  be  administered  an  hour  beforehand  to  quiet  irritability  and 
facilitate  the  operation.  Cicatricial  strictures  will  not  yield  to  such 
treatment,  however,  and  had  better  not  be  irritated  by  efforts  to  dilate 
them.  Attention  to  the  diet  and  such  other  palliative  measures  as 
individual  cases  may  demand  are  all  that  can  be  adopted,  unless 
a  gastric  fistula  for  the  introduction  of  food  directly  into  the  stomach 
is  established. 

Cancerous  stricture  should  not  be  disturbed,  as  irritation  usually 
augments  the  rapidity  of  its  development;  all  that  we  can  expect  to 
do  here  is  to  relieve  the  pain  which  attends,  and  we  may  accomplish 
this  usually  with  ten-  or  fifteen-drop  doses  of  echinacea.  Silica  3x 
is  an  excellent  remedy  for  this  purpose,  three-grain  doses  of  the  trit- 
uration  being  used  three  or  four  times  a  day,  though  it  is  second  to 
echinacea  in  value.  Where  the  ulceration  which  causes  the  obstruc- 
tion is  non-malignant  a  stomach-pump  may  sometimes  be  used  suc- 
cessfully in  introducing  nourishment. 

Chelidonium  majus  has  recently  attracted  attention  as  an  internal 
remedy  for  curative  effects  in  cancer  generally.  Cures  of  unmistak- 
able cancer  of  the  oesophagus  and  stomach  have  been  reported  by 
apparently  respectable  authority.  Small  doses,  frequently  repeated, 
for  a  long  time,  were  required  to  remove  the  morbid  growths. 

Syphilis,  bronchocele,  hydropericardium  and  other  special  causes 
of  cesophageal  obstruction  will  demand  special  treatment,  adapted  to 
the  condition  present. 

FUNCTIONAL  DISEASE  OF  THE  (ESOPHAGUS. 

PARALYSIS  of  the  O3sophagus  sometimes  attends  diphtheria  and 
hysteria,  and  arises  from  glosso-pharyugeal  paralysis  and  general 
paralysis  of  the  insane.  It  also  attends  progressive  muscular  paral- 
ysis and  certain  diseases  of  the  brain. 


DISEASES  OF  THE  (ESOPHAGUS.  375 

Symptoms. — Djsphagia  is  the  only  prominent  symptom.  The 
food  may  escape  and  pass  into  the  larynx,  producing  serious  respira- 
tory embarrassment,  this  being  especially  true  of  liquids.  Degluti- 
tion is  facilitated  by  the  erect  posture. 

(ESOPHAGISMUS,  or  spasm  of  the  oasophagus,  may  occur  in  hys- 
teria, in  hypochondria,  in  muscular  rheumatism  or  from  an  irritable 
ulcer  in  the  passage.  It  may  also  be  caused  by  the  bolting  of  large 
lumps  of  solid  food,  by  swallowing  extremely  hot  or  cold  food,  or  by 
the  abuse  of  alcohol.  Irritation  of  the  oesophageal  nerves  may  also 
be  a  cause,  and  dyspeptic  symptoms  are  sometimes  attended  by  it. 
Rectal  irritation,  lacerated  cervix  uteri,  adherent  prepuce  or  clitoris 
and  other  orificial  lesions  may  be  accountable  for  it. 

Prominent  among  the  symptoms  is  a  sensation  of  obstruction  as 
from  a  solid  substance  in  the  gullet;  and  when  food  is  taken  there  is 
stoppage  of  the  bolus  upon  swallowing  at  some  point  in  the  passage. 
These  symptoms  are  temporary  and  appear  erratically,  as  the  excit- 
ing cause  provokes  spasmodic  action.  There  may  be  quite  long  in- 
tervals during  which  there  is  no  difficulty  whatever  in  swallowing. 
If  a  bougie  be  passed  while  the  spasmodic  action  is  on  its  course  is 
arrested  at  the  point  of  contraction,  but  if  steady  pressure  be  main- 
tained against  it  at  the  place  of  resistance  there  is  soon  yielding  and 
the  instrument  passes  the  obstruction  easily.  During  severe  attacks 
there  is  a  sensation  of  constriction  and  suffocation  about  the  throat 
due,  probably,  to  spasm  of  the  cervical  muscles.  When  it  occurs  in 
muscular  rheumatism  it  is  due  to  metastasis  of  the  rheumatic  affec- 
tion, pain  then  attending  the  sense  of  obstruction  and  suffocation. 
The  upper  portion  of  the  oasophagus  is  usually  involved.  Little  con- 
stitutional disturbance  is  present,  the  patient  appearing  well  nour- 
ished, though  dyspeptic,  hysterical  and  hypochondriacal  symptoms 
are  common  in  most  such  cases. 

Treatment. — Bromide  of  potassium  allays  spasm  and  hyperses- 
thesia  of  the  oesophagus  and  is  almost  always  an  appropriate  remedy 
in  cesophagismus.  From  ten  to  twenty  grains  may  be  administered 
every  two  or  three  hours  while  the  active  symptoms  continue.  It 
rarely  affords  permanent  relief,  but  it  is  useful  to  relieve  speedily. 
Markedly  hysterical  cases  should  receive  specific  gossypium  in  ten- 
drop  doses  four  or  five  times  daily  until  the  spasmodic  symptoms 
subside.  Valerianate  of  ammonium,  tincture  of  valerian  and  valerian- 
ate  of  zinc  are  all  useful.  Naja  relieves  spasm  of  the  oasophagus 
where  the  oesophageal  nerves  are  irritated.  Rheumatic  complications 
demand  cimicifuga  or  rhamnus  californica.  Faradism  often  does  good, 
the  positive  pole  being  applied  to  the  tongue  with  a  metal  tongue- 
depressor  while  a  wetted  sponge  attached  to  the  negative  is  held 
against  the  epigastrium. 


376  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

In  all  these  cases  careful  inspection  of  the  rectum,  cervix  uteri 
and  other  orifices  should  be  made  to  detect  any  irritation  there,  and 
if  this  be  found  present  the  removal  of  the  difficulty  by  proper  ori- 
ficial  surgery  is  the  correct  course  to  pursue. 

VI.    DISEASES  OF  THE  STOMACH. 

ACUTE  GASTRITIS. 

Synonyms. — Acute  Gastric  Catarrh;  Acute  Dyspepsia. 

Definition. — An  acute  inflammation  of  the  mucous  membrane 
of  the  stomacn. 

Etiology. — Ordinary  causes  of  inflammation  of  the  mucous 
membranes  generally,  such  as  sudden  arrest  of  secretion  from  cold 
while  the  person  is  relaxed,  may  excite  this  condition  in  people  who 
ar«  delicate  in  respect  to  the  state  of  the  digestive  organs.  The  ac- 
tion of  hot  or  cold  articles  of  food  is  calculated  to  bring  on  acute 
gastritis,  and  certain  chemicals,  such  as  alcohol,  strong  acids,  arsenic, 
etc.,  may  excite  a  high  grade  of  inflammatory  action  when  allowed  to 
enter  the  stomach  in  concentrated  form.  Some  diseases  incline  to 
bring  about  the  condition;  as,  for  instance,  cholera  morbus,  cholera, 
yellow  fever,  etc.  Acute  gastritis  attended  by  febrile  symptoms  some- 
times occurs  epidemically.  The  predisposing  conditions  are  dis- 
ordered states  of  the  gastric  mucosa,  which  place  its  vitality  below 
par,  as  in  elderly  persons  or  delicate  women  and  children,  in  whom  the 
stomach  is  in  an  enfeebled  condition,  the  disease  being  here  pro- 
voked by  indiscretions  in  diet. 

Pathology. — There  are  different  grades  of  acute  gastritis.  Ex- 
posure of  the  mucous  membrane  of  the  stomach  through  a  gastric 
fistula  has  afforded  opportunity  to  watch  the  condition  of  the  mucous 
membrane  during  life  when  inflamed,  and  it  has  been  seen  that  the 
part  is  reddened  and  that  a  coating  of  mucus  is  thrown  out  over  the 
reddened  surface.  The  redness  in  moderate  cases  occurs  in  patches, 
the  hyperaemia  being  punctiform  or  capillary  in  character;  but  when 
irritant  poisoning  occurs  the  entire  mucous  membrane  is  highly  red- 
dened and  swollen,  that  upon  the  summits  of  the  rugae  suffering 
most.  Small  extravasations  may  appear,  and  minute  ulcers  and  fol- 
licular  erosions  are  not  uncommon.  In  very  severe  cases  suppura- 
tion and  sloughing  of  the  submucous  structure  may  occur.  The  pep- 
tic and  mucous  glands  are  also  involved,  the  cells  aud  nuclei  being 
enlarged  and  increased  in  number,  the  tubules  being  elongated  and 
prominent.  The  secretion  of  gastric  juice  is  thus  interfered  with,  an 
alkaline,  ropy  mucus  covering  the  surface.  The  lymphoid  elements 
between  the  glands  are  increased  in  number  and  hypertrophied. 


DISEASES  OF  THE  STOMACH.  377 

Many  mild  cases  of  gastritis  occur  in  which  such  marked  changes  are 
absent,  a  punctiform  redness  of  the  mucous  membrane  with  increase 
of  catarrhal  secretion  being  the  extent  of  the  morbid  condition. 

Symptoms. — These  vary  widely,  according  to  the  severity  of  the 
inflammation.  In  mild  cases  there  are  symptoms  of  indigestion,  such 
as  unpleasant  sensations  in  the  epigastric  region — burning,  nausea, 
eructations,  and  vomiting  which  is  followed  by  relief.  Constipation 
may  attend,  though  there  is  sometimes  diarrhoea,  especially  in  chil- 
dren. The  tougue  is  coated  and  there  is  an  excessive  amount  of 
saliva,  attended  by  metallic  taste.  Such  cases  subside  within  twenty- 
four  hours  usually,  as  they  result  from  slight  causes  and  depend  on 
individual  susceptibility.  Severe  cases  are  marked  by  burning  pains, 
often  of  excruciating  character,  which  invade  the  epigastric  region 
and  radiate  throughout  the  entire  abdomen,  colicky  sensations  alter- 
nating. The  inflammation  may  be  marked  by  a  chill  and  febrile  ac- 
tion (102° — 104°  R).  Vomiting  is  a  common  symptom  and  is  re- 
peated frequently,  the  tongue  being  furred  and  the  breath  offensive. 
Food  is  ejected  at  first,  but  bile  mixed  with  mucus  and  watery  fluids 
appears  in  the  ejections  later,  there  being  absence  of  hydrochloric 
acid,  a  presence  of  lactic  and  fatty  acids  and  a  superabundance  of 
mucus.  The  urine  presents  the  usual  characteristics  of  febrile  ac- 
tion, an  abundant  deposit  of  urates  being  thrown  down. 

In  gastritis  from  toxic  poisoning  there  is  burning  pain  in  the 
mouth,  throat,  ossophagus,  stomach  and  bowels,  watery  diarrhoea 
(when  arsenical),  ptyalism,  difficult  deglutition  and  frequent  vomiting 
(the  ejections  containing  blood  and  sometimes  portions 'of  mucous 
membrane),  while  the  abdomen  is  swollen  and  tender  upon  pressure. 
In  extreme  cases  collapse  may  occur,  the  pulse  being  thready,  the 
respiration  labored,  the  skin  cold  and  covered  with  clammy  sweat 
and  the  patient  extremely  restless  and  anxious. 

Diagnosis. — When  the  disease  occurs  without  any  well-pro- 
nounced cause,  it  may  at  first  be  mistaken  for  some  form  of  infectious 
fever  announced  by  active  gastric  irritation,  as  is  sometimes  the  case 
in  scarlatina  and  other  infections.  Later  developments,  however, 
will  distinguish  it  from  these  affections.  "When  irritating  drugs  have 
been  swallowed  a  knowledge  of  this  fact  will  enable  us  to  decide  as 
to  the  character  of  the  complaint.  The  experience  of  delicately  con- 
stituted persons  who  suffer  from  gastritis  from  slight  causes  will 
assist  the  physician  in  most  cases  in  arriving  at  a  correct  diagnosis. 

Prognosis. — Snch  cases  as  are  marked  by  dietary  indiscretions 
usually  recover  within  two  or  three  days.  Others  may  run  a  still 
more  violent  course,  depending  on  the  gravity  of  the  exciting  cause, 
a  chronic  gastric  catarrh  being  finally  established.  Poisoning  with 
arsenic  or  other  corrosive  poisons  is  liable  to  run  a  still  more  severe 


378  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

course,  the  symptoms  of  toxic  poisoning  being  sometimes  of  grave 
and  fatal  character. 

Treatment. — In  mild  cases  of  acute  gastritis  diluents  may  be 
used  to  favor  emesis.  These  may  be  warm  water,  flax-seed  tea, 
slippery-elm  water  or  some  other  soothing  agent.  Following  this 
a  decoction  of  the  bark  of  peach-tree  shoots,  a  weak  infusion  of 
hydrastis  or  (what  is  better)  the  following  prescription  may  be  admin- 
istered: R  Green  plant  tincture  rhus  tox.  gtt.  xv,  specific  ipecac  gtt. 
x,  water  ?iv.  M.  Sig.  Take  a  teaspoonful  every  hour.  Sometimes 
two  grains  of  subnitrate  of  bismuth  every  hour  will  serve  a  better  pur- 
pose. For  the  treatment  of  poisoning  the  reader  is  referred  to 
works  on  toxicology. 

PHLEGMONOUS   GASTRITIS. 

Symptom. — Suppurative  Lenitis. 

Definition. — A  suppurative  inflammation  of  the  submucous 
(areolar)  tissue  of  the  stomach. 

Etiology. — This  disease  is  rare  and  usually  occurs  between  the 
ages  of  twenty  and  forty  years.  It  may  arise  from  the  infection  of 
pyaemia,  septicaemia,  typhoid  or  typhus  fever,  or  diarrhoea  as  a  sec- 
ondary affection  or  may  occur  idiopathically.  Traumatism  may  be 
an  occasional  cause. 

Pathology. — The  inflammation  may  be  circumscribed  or  dif- 
fused. The  wall  of  the  stomach  at  the  point  of  inflammatory  action 
is  thickened,  oadematous  and  friable,  with  infiltration  of  the  areolar 
tissue  with  sero-fibrinous  and  purulent  material.  In  the  diffused 
form  the  mucous  membrane  may  be  thinned  and  perforated  in  num- 
erous places,  affording  exit  to  pus  from  a  variety  of  irregularly  shaped 
cavities  located  in  the  submucous  tissue.  The  mucous  surface  is 
reddened,  sometimes  dusky  in  hue,  and  gangrenous  spots  may  appear 
in  various  places.  Sometimes  the  peritoneal  coat  is  involved,  the 
condition  then  assuming  the  characteristics  of  acute  peritonitis. 
Pus  may  perforate  this  membrane  and  escape  into  the  peritoneal 
cavity.  Gastric  ulcers  may  arise  from  perforation  of  the  mucous 
membrane. 

Symptoms. — Active  febrile  symptoms  usher  in  this  disease. 
There  is  a  chill,  followed  by  febrile  reaction,  the  temperature  rising 
as  high  as  104°  or  106°  F.  There  is  intense  pain  in  the  epigastric  re- 
gion, with  loss  of  appetite  and  consuming  thirst.  Persistent  vomiting 
of  a  dark  colored,  bitter  fluid  containing  more  or  less  pus  succeeds 
early  upon  the  initial  chill,  the  patient  is  rapidly  prostrated  and  be- 
comes anxious  and  watchful.  Delirium  with  jaundice  soon  follows,  and 
typhoid  symptoms  with  muttering,  wandering  or  stupor  precede  the 


DISEASES  OF  THE  STOMACH.  379 

period  of  collapse  (which  is  soon  developed),  the  patient  dying  in  a 
comatose  condition. 

Diagnosis. — This  is  very  difficult,  and  the  disease  is  usually 
unrecognized  during  life,  autopsies  supplying  the  most  that  has  been 
known  upon  the  subject. 

Prognosis. — This  is  always  unfavorable.  The  majority  of  cases 
prove  fatal  within  the  first  week,  especially  if  the  inflammation  be 
diffused.  Circumscribed  inflammation  here  may  not  prove  so  rapidly 
fatal,  the  patient  surviving  for  two  or  three  weeks.  Secondary 
abscess  of  the  liver  and  peritonitis  may  attend. 

Treatment. — This  is  principally  palliative,  hypodermic  injec- 
tions of  morphia  being  most  reliable  to  relieve  the  pain.  Hypoder- 
mic injections  of  ecliafolta  might  be  tried  for  the  control  of  the  in- 
flammatory action  and  to  prevent  extreme  destruction  of  tissue. 

PARASITIC  GASTRITIS. 

FUNGI  occasionally  develop  in  the  stomach  and  excite  inflamma- 
tion. Sarcinse  and  yeast  fungi  are  probably  perpetuating  causes  of 
chronic  gastritis,  and  occasionally  a  case  of  acute  gastritis  seems 
ascribable  to  the  presence  of  parasitic  growths.  The  anthrax  bacil- 
lus has  been  known  to  develop  in  the  gastric  mucous  membrane  and 
Klebs  has  described  a  bacillus  gastricus  which  develops  in  the  gas- 
tric tubules  and  excites  acute  gastritis.  The  larvae  of  certain  insects 
has  been  known  to  cause  gastritis.  Diphtheria,  tuberculosis  and 
syphilis  may  attack  the  gastric  mucous  membrane. 

CHRONIC  GASTRITIS. 

Synynoms. — Chronic  Gastric  Catarrh;  Chronic  Dyspepsia. 

Definition. — It  is  a  disturbance  of  digestion  attended  by  an 
excess  of  gastric  mucous  secretion,  with  vitiation  of  the  digestive 
juices  from  fermentative  products,  and  finally  alteration  of  the  struc- 
tural integrity  of  the  stomachal  walls. 

Etiology — The  causes  of  this  condition  are  numerous  and  varied 
in  character,  but  all  tend  to  one  result — difficult  and  protracted 
chymification,  with  formation,  within  the  stomach,  of  fermentative 
material.  This  may  result  from  acute  gastritis,  though  it  is  more 
apt  to  come  on  from  indiscretions  in  diet,  such  as  the  use  of  highly 
seasoned  or  indigestible  food;  irregular  and  hasty  eating;  gourman- 
dizing;  addiction  to  the  excessive  use  of  tea,  coffee,  alcohol  or  tobac- 
co or  from  the  habit  of  using  iced  foods  or  drinks  during  meals.  It 
may  develop  from  rectal,  prostatic  or  uterine  irritation  and  such  con- 
stitutional diseases  as  gout,  anaemia,  chlorosis,  tuberculosis  and  dia- 


380  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

betes,  and  malarial  cachexia  may  be  attended  or  preceded  by  it 
Pulmonary  tuberculosis  or  chronic  interstitial  nephritis  may  be  her- 
alded for  months  by  gastric  catarrh  long  before  the  pending  causal 
disease  has  Ijeen  fully  developed,  slow  and  inadequate  digestion  en- 
couraging the  growth  of  the  yeast  plant,  sarcina  and  other  elements 
of  gastric  fermentation,  thus  giving  rise  to  and  perpetuating  irrita- 
tion of  the  gastric  mucosa.  Portal  obstruction,  by  causing  engorge- 
ment of  the  gastric  capillaries,  may  retard  digestion  and,  finally, 
through  disturbance  of  the  functions  of  the  gastric  tubules  and  re- 
sultant slow  and  feeble  digestion,  permit  the  accumulation  of  suffi- 
cient provoking  cause  to  bring  on  a  chronic  catarrh,  it  therefore  be- 
ing frequently  associated  with  active  or  passive  hepatic  congestion, 
hepatic  cirrhosis,  splenic  hypertrophy,  pancreatic  disease  or  cardiac 
or  pulmonary  engorgement.  Also,  it  may  be  associated  with  various 
local  diseases  of  the  stomach,  such,  for  example,  as  cancer,  ulcera- 
tion  or  dilatation. 

Pathology. — Pathologists  recognize  two  forms  of  chronic  gas- 
tritis: (1)  The  simple  or  common,  and  (2)  the  sclerotic — the  second 
being  rare.  The  simple  form  is  attended  by  hypertrophy  of  the  in- 
tertubular  mucous  membrane  with  consequent  choking  out  of  the 
gastric  tubules;  while  the  second  is  attended  by  atrophy  of  the  entire 
mucous  membrane  as  well  as  of  the  secreting  structures.  The  first 
is  marked  by  profuse  secretion  of  mucus  with  restriction  of  the  nor- 
mal amount  of  gastric  juice,  the  lining  of  the  stomach  being  covered 
with  a  tenacious  coating  which  mechanically  and  chemically  inter- 
feres with  normal  chymification,  while  the  second  is  characterized  by 
dryness  and  lack  of  secretion  not  only  of  gastric  juice  but  of  mucus, 
the  organ  being  dilated,  its  walls  thinned  and  atrophied,  with  fatty 
degeneration  of  its  glandular  elements.  In  another  sclerotic  form 
(which  is  exceedingly  rare)  there  is  fibrous  degeneration  of  the  gas- 
tric walls,  the  muscular  structure  being  thickened  with  fibrous  growth 
from  hyperplasia  of  the  connective  tissue  until  the  coats  are  con- 
tracted and  hardened,  the  viscus  being  lessened  in  size  and  concen- 
trated until  its  outlines  may  be  traced  by  palpation  through  the  ab- 
dominal walls. 

In  the  common  form  removal  of  the  tenacious  gray  mucus  cover- 
ing the  interior  of  the  stomach  will  reveal  more  or  less  alteration  of 
structure  in  the  mucous  membrane,  the  amount  and  character  depend- 
ing upon  the  duration  and  severity  of  the  disease.  CEdematous  spots 
covered  with  granulations,  ecchymoses  and  more  or  less  extensive 
areas  of  pigmentation  are  distributed  over  the  surface.  Thickening 
of  the  mucous  membrane  is  prominent,  especially  about  the  pylorus, 
and  this  may  be  so  extensive  as  to  obstruct  the  opening,  the  stenosis 
resulting  in  gradual  dilatation — gastrectasia.  In  some  cases  the  sub- 


DISEASES  OF  THE  STOMACH.  381 

mucous  tissue  is  implicated,  the  thickening  being  attended  by  infil- 
tration of  the  structure  with  migrating  connective-tissue  cells  and 
development  of  adventitious  fibrous  growth,  which  renders  the  walls 
firm  and  unwieldy  and  interferes  greatly  with  normal  peristaltic 
action.  Mammillation  of  the  surface  of  the  mucous  membrane 
due  to  obstruction  of  the  tubules  by  pressure  from  intertubular 
hypertrophy,  and  consequent  distention  by  accumulation  of  their 
secretions  until  they  stand  out  prominently,  may  sometimes  be  ob- 
served. Another  form  of  mammillation  is  that  which  attends  hyper- 
trophy of  the  peptic  glands,  this  resulting  in  an  increased  area  of 
mucous  surface,  which  being  more  voluminous  than  the  basement 
membrane  is  thrown  into  folds  or  corrugations.  As  the  disease  con- 
tinues the  muscular  coats  may  become  still  more  involved  in  the 
thickeniug  process  and  the  peristaltic  movements  will  become  fur- 
ther impeded.  Finally,  the  serous  layer  may  be  involved  and  ad- 
hesions occur  between  opposing  surfaces  of  the  reflected  peritonaeum. 

In  long-standing  cases  the  mucous  membrane  near  the  pylorus  is 
very  liable  to  be  the  seat  of  abrasions,  superficial  ulcers  of  circular 
shape,  varying  from  half  an  inch  to  an  inch  in  diameter,  occupying 
this  region,  the  intervening  mucous  membrane  being  reddened  and 
osdematous.  The  ulcers  are  superficial,  rarely  extending  deeper  than 
the  mucous  membrane,  their  bases  being  covered  with  mucous  cells, 
epithelium  and  nuclei.  Minute  points  of  ulceration  may  appear, 
scattered  about  over  the  entire  surface,  marking  the  locations  of 
similarly  affected  solitary  and  lenticular  glands.  The  inflammation 
usually  extends  to  the  duodenal  mucous  membrane,  similar  changes 
occurring  here,  and  the  common  bile  duct  may  be  involved  during 
aggravations,  icteric  symptoms  from  obstruction  at  various  intervals 
signalizing  such  complication.  Dilatation  of  the  stomach  may  attend 
some  cases  and  contraction  of  its  wsdls  others,  as  varying  pathologi- 
cal changes  predominate.  Amyloid  degeneration  of  the  walls  of  the 
stomach,  secondary  to  waxy  changes  in  the  liver  and  spleen,  may 
occur  in  advanced  stages.  Fatty  infiltration  of  the  tubules  is  detected 
under  the  microscope,  and  occasionally  fatty  degeneration  of  the  tub- 
ular structures. 

Symptoms. — Indigestion  is  the  prominent  symptom,  a  great 
variety  of  unpleasant  accompaniments  being  liable  to  attend.  Heart- 
burn, associated  with  weight  and  fullness  in  the  epigastric  region, 
follows  eating  and  continues  for  hours  as  soon  as  the  disease  devel- 
ops. Later  on  there  is  actual  pain  of  a  burning,  acrid  nature,  at- 
tended by  eructations  of  gases  and  fluids,  sour  risings  and  tenderness 
on  pressure  over  the  epigastrium.  Darting  pains  radiate  from  the 
stomach  into  the  pectoral  region  and  backward  toward  the  scapulae, 
and  these  may  be  aggravated  by  pressure  over  the  epigastrium. 


382 


DISEASES  OF  THE  DIGESTIVE  ORGANS. 


Burning  along  the  oesophagus  and  in  the  throat  and  mouth,  with  in- 
creased secretion,  is  common,  the  lips  and  tongue  sharing  in  the  un- 
pleasant sensation.  The  tongue  is  often  red  and  slick,  the  papillae 
being  elevated  and  the  tip  pointed,  though  in  other  cases  the  general 
appearance  of  the  organ  may  be  normal.  Craving  for  food  (boulimia) 
is  a  frequent  symptom,  this  amounting  in  many  instances  to  an  almost 
constant,  unsatisfied,  gnawing  sensation  in  the  epigastrium,  though  a 
small  portion  of  food  may  satisfy  it  for  a  short  time,  during  which 
the  torments  of  difficult  and  painful  digestion  are  experienced.  A 
metallic  taste  is  frequently  present  between  periods  of  eating. 

In  aggravated  cases  vomiting  is  a  frequent  symptom,  the  material 
ejected  consisting  of  partially  digested  food  mixed  with  a  large  quan- 
tity of  mucus,  among  which  may  be  detected  sarcinee  ventriculi,  toru- 
l?e  and  varieties  of  bacilli  and  micrococci.  There  is  absence  of  hydro- 
chloric acid  here  in  most  cases,  lactic  acid,  associated  with  butyric 
or  acetic  acid  replacing  it,  though  in  rare  cases  there  may  be  excess- 
ive secretion  of  hydrochloric  acid.  Digestion  is  necessarily  retarded 

under  these  circumstances,  and 
if  the  stomach  be  irrigated  and 
siphoned  seven  hours  after  eat- 
ing undigested  food  will  still 
be  found  in  the  washings. 

The  bowels  are  usually  con- 
stipated, though  the  reverse 
may  be  the  case,  undigested 
food  then  passing  thiough  the 
intestinal  canal  soon  after  it  is 
swallowed  (lientery). 

Cardiac  palpitation  fre- 
quently attends  the  digestive 
process  and  the  tumultuous 
throbbing  may  seem  to  be  com- 
municated to  the  sensitive 
stomach,  accumulation  of  gases 
aggravating  the  difficulty  and  eructation  affording  only  temporary 
relief.  Stitching  pains  in  the  cardiac  region  may  be  added  to  the 
tumultuous  action  and  vertigo  is  often  associated  with  it  "Stomach 
cough,"  due  to  pharyngeal  irritation  partly  and  partly,  in  many  cases, 
to  voluntary  efforts  of  the  sufferer  in  seeking  relief  from  prsecordial 
oppression  and  epigastric  discomfort,  often  attends. 

Among  the  sympathetic  symptoms  are  headache,  langour,  mel- 
ancholy and  emaciation.  Where  atropy  of  the  gastric  tubules  is 
present  anaemia  is  prominent. 

Diagnosis. — The  use  of  the  stomach-tube  will  afford  the  best 


MICROSCOPICAL  DEBRIS  FROM  CATARRHAL  STOMACH. 

a,  Rarcinae  ventriculi. 

b,  yenst  plant. 

c,  bacteria  and  cocci, 
cl,  epithelial  cells. 

e,  leucocytes. 

f,  starch  granules, 

g,  fat  globules. 

h,  muscular  fiber. 
i,  fat  needles, 
k,  vegetable  cells. 


DISEASES  OF  THE  STOMACH.  383 

means  of  diagnosis.  If  siphonage  be  practiced  an  Lour  or  so  after 
eating  hydrochloric  acid  will  usually  be  absent,  and  lactic  acid  asso- 
ciated with  fatty  acids  appears,  a  large  amount  of  rnucus  being  pres- 
ent. If  siphonage  be  practiced  seven  hours  after  eating  undigested 
food  will  be  found  still  remaining  in  the  stomach,  while  in  cases  of 
functional  dyspepsia  it  will  have  disappeared.  Malignant  disease 
will  be  excluded  by  lack  of  cachexia,  absence  of  perceptible  tumor 
upon  palpation  and  by  the  character  of  the  vomit,  coffee-ground 
material  soon  appearing  in  cancer.  In  gastric  ulcer  a  diagnostic 
feature  is  hematemesis  of  bright  blood. 

Prognosis. — Chronic  gastritis  will  usually  improve  readily 
under  rational  treatment,  unless  there  be  associated  with  it  gastric 
ulcer,  cancer,  gastrectasia  or  organic,  hepatic,  renal  or  pulmonary  dis- 
ease. When  neglected  it  may  continue  for  years  and  eventually  ter- 
minate in  ulcer  or  pyloric  stenosis,  with  resultant  perforation  or  dil- 
atation. A  sympathethic  disease  of  the  supra-renal  capsules  is  not 
an  unfrequent  complication,  the  supra-renal  bodies  seeming  to  sus- 
tain a  peculiar  relation  of  this  nature  to  gastric  irritation.  The 
marked  emaciation  which  attends  long-continued  cases  renders  the 
patient  susceptible  to  attacks  of  acute  disease  and  he  is  liable  to  suc- 
cumb suddenly  to  some  onset  of  this  kind,  to  hematemesis  or  to  the 
immediate  results  of  pyloric  stricture. 

Treatment. — An  important  part  of  treatment  is  the  abandon- 
ment, so  far  as  possible,  of  all  exciting  or  perpetuating  causes.  If 
the  subject  has  been  in  the  habit  of  using  alcoholic  liquors  he  should 
do  away  with  them  at  once  and  forever.  As  a  substitute  three  parts 
of  Howe's  viburnum  cordial  and  one  part  of  specific  avena  saliva 
should  be  combined,  and  recourse  be  had  to  this  mixture  in  accept- 
able doses  repeated  as  often  as  necessary  until  all  depression  and 
craving  for  the  accustomed  stimulant  have  passed  away.  A  habit  of 
using  ice-water  or  iced  drinks  or  foods  should  be  dispensed  with 
under  all  circumstances,  warm  foods  and  drinks  of  bland  and  digesti- 
ble character  being  most  applicable  to  restorative  processes.  Over- 
eating and  the  use  of  objectionable  food  should  be  avoided — and  this 
will  be  no  easy  trial  for  the  patient  if  he  be  permitted  to  dine  in 
the  company  of  healthy  persons,  as  the  food  they  may  be'  accus- 
tomed to  may  not  be  applicable  to  his  case,  and  the  power  of  associa- 
tion may  be  so  strong  as  to  lead  him  to  transgress  again  and  again 
to  the  complete  defeat  of  curative  measures.  It  will  be  better  for 
him  to  eat  alone  and  confine  himself  to  small  quantities  of  judiciously 
selected  foods  taken  at  shorter  intervals  than  in  health,  with  slow 
mastication.  Fats  and  carbo-hydrates  should  be  generally  avoided 
as  well  as  pastries,  griddle-cakes  and  cheese. 

Sometimes,  when  there  is  nephritic  or  cardiac  complication  (and 


384  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

even  in  severe  cases  without  complication),  a  milk  diet  adheied  to 
strictly  for  several  weeks  will  afford  the  best  results.  In  order  to 
prevent  the  formation  of  hard  curds  the  milk  should  be  diluted  with 
soda-water,  lime-water  or  other  alkaline  fluid.  Where  there  is  atro- 
phy of  the  peptic  glands  pancreatized  milk  will  be  more  appropriate. 
Sometimes,  when  the  stomach  is  very  weak  and  the  milk  causes 
nausea,  it  may  be  necessary  to  remove  the  cream  before  it  is  taken. 
Many  persons  will  prefer  butter-milk,  and  this  may  be  allowed  freely 
in  such  cases.  From  one  to  two  quarts  of  milk  or  butter-milk  may 
be  taken  every  twenty-four  hours,  four  ounces  being  allowed  at  a 
time  with  two-hour  intervals,  the  amount  being  gradually  increased 
and  the  intervals  lengthened  as  improvement  succeeds. 

When  milk  does  not  sustain  the  strength  (though  such  cases  will 
be  rare)  underdone  beef  or,  what  is  better,  raw  scraped  beef  may  be 
allowed  in  connection  with  it,  one  or  two  ounces  at  a  time  two  or 
three  times  a  day  being  sufficient,  though  the  amount  may  be  in- 
creased as  the  patient's  ability  to  digest  food  improves.  Broths  and 
soups  should  be  avoided  and  tea,  coffee  and  cocoa  should  be  taken 
sparingly  if  at  all  and  without  milk  or  sugar.  Oysters  raw,  broiled 
or  panned  are  allowable  and  also  stale  bread  without  butter  or  with 
but  a  sparing  quantity.  Where  there  is  an  excessive  amount  of 
hydrochloric  acid  secreted  the  patient  will  live  best  on  rare  roast 
beef,  rare  steaks  or  the  breast  of  chicken  eaten  with  stale  bread. 
Eggs  should  be  thoroughly  cooked  for  such  persons  and  will  then  be 
well  tolerated.  If  an  egg  be  boiled  for  an  hour  the  yolk,  with  a  lit- 
tle salt  added,  will  agree  with  the  most  delicate  stomach.  Where 
there  is  a  strong  tendency  for  food  to  undergo  decomposition  in  the 
stomach  salted  and  smoked  meats  and  fish  may  sometimes  agree  bet- 
ter than  other  articles  of  diet.  Here  cream  codfish,  dried  beef,  jerked 
venison,  caviar,  etc.,  may  be  carefully  tried  in  succession  in  small 
quantities,  that  the  diet  be  varied.  Cured  meats  may  be  employed 
for  the  manufacture  of  cream  gravy  to  be  eaten  on  toast  or  stale 
bread,  the  solid  part  being  rejected. 

Confusion  as  to  a  proper  course  of  diet  may  be  avoided  if 
the  patient  can  be  induced  to  adhere  to  a  strictly  dry  diet.  This 
should  consist  only  of  stale  bread,  to  be  taken  ad  libitum  with  two  or 
three  ounces  at  a  time  of  plain  claret,  which  should  not  be  repeated 
oftener  than  five  or  six  times  each  twenty-four  hours.  No  tea,  cof- 
fee, water,  milk  or  other  fluid  should  be  allowed,  and  no  butter,  meat 
or  other  food,  except  the  plain,  stale  bread,  should  be  consumed. 
This  may  seem  a  hardship  at  first,  but  adherence  to  the  regimen 
brings  abundant  satisfaction  by  the  end  of  ten  or  twelve  weeks. 
There  will  be  a  provoking  thirst  for  the  first  few  days,  after  which 
this  source  of  annoyance  will  have  subsided.  Upon  this  allowance 


DISEASES  OF  THE  STOMACH.  385 

the  patient  will  not  over-eat  and,  though  he  may  become  emaciated 
and  weakened  somewhat,  he  will  not  starve,  and  will  recuperate  rap- 
idly when  a  gradual  return  to  ordinary  diet  is  allowed,  while  the 
gastric  disturbance  will  have  subsided — if  other  proper  measures 
have  been  applied  in  the  meantime. 

Saccharine,  starchy  and  farinaceous  foods  are  almost  certain  to 
undergo  lactic  and  butyric  acid  fermentation  in  the  stomach  before 
their  digestion  can  be  completed,  producing  flatulency  with  eructa- 
tion of  gasee  and  sour  fluids.  A  person  afflicted  with  chronic  gas- 
tritis should  endeavor  to  live  carefully  and  abstemiously  after  re- 
covery throughout  his  life,  as  it  is  not  a  difficult  matter  to  prov,  ke 
a  return  of  the  disease.  During  treatment,  business  cares  and  all 
other  responsibilities  should  be  avoided,  that  no  expenditure  of  en- 
ergy be  made  in  an  unnecessary  direction,  neither  physical  nor  men- 
tal exertion  being  conducive  to  improvement.  The  case  of  Louis 
Cornaro,  the  Venetian,  is  not  to  be  forgotten  in  this  connection,  for 
it  illustrates  the  remarkable  effect  of  careful  living  upon  those  seem- 
ingly hopelessly  affected  with  gastric  derangements. 

Though  my  information  does  not  justify  me  in  asserting  that  he 
was  a  sufferer  from  chronic  gastritis,  the  narrative  suggests  such  a 
condition.  Born  with  wealth,  he  was  endowed  with  means  and  leis- 
ure to  abandon  himself  to  high  and  prodigal  living;  but  a  weak  con- 
stitution, broken  down  at  the  age  of  thirty-five  from  riotous  living 
and  other  excesses,  rendered  life  a  burden  to  him.  The  next  five 
years  were  passed  in  almost  constant  misery,  and  at  the  age  of  forty 
his  physician  informed  him  that  nothing  could  prolong  his  life  more 
than  two  or  three  years,  and  temperate  habits  were  advised  as  the 
means  to  relieve  his  sufferings  during  that  time.  He  now  began  to 
gradually  reduce  the  amount  of  food,  both  liquid  and  solid,  consumed, 
until  he  at  length  took  only  what  nature  absolutely  required.  This, 
according  to  his  own  statement,  was  a  difficult  course  to  pursue  and 
he  often  relapsed  to  over-eating;  but  he  finally  succeeded  (within  a 
year)  in  adopting  permanently  a  spare  and  moderate  system  of  diet, 
and  was,  at  the  end  of  this  time,  already  restored  to  perfect  health. 

Being  now  an  enthusiast,  he  proceeded  from  moderation  to  abste- 
miousness and  diminished  his  daily  allowance  until  the  yolk  of  an 
egg  sufficed  him  for  a  meal.  Health  and  spirits  improved  and  he 
soon  became  able  to  derive  more  pleasure  from  a  small  meal  of  dry 
bread  than  the  most  tempting  viands  of  a  richly-laden  table  had 
afforded  him  in  his  days  of  excesses.  Such  a  course  persevered  in, 
with  the  avoidance  of  extremes  of  heat  and  cold,  enabled  him,  after 
almost  ending  his  life  at  thirty-five,  to  recuperate  and  become  a  cen- 
tenarian. Modern  experiences  often  acquaint  us  with  similar  cases, 
where  individuals  in  desperation,  after  a  prolonged  treatment  for 

26 


386 


DISEASES  OF  THE  DIGESTIVE  ORGANS. 


indigestion  without  benefit,  recover  under  prolonged  self-imposed 
starvation. 

Constant  and  prolonged  fermentation  is  the  principal  factor  in 
the  perpetuation  of  the  disease,  and  the  cleansing  of  the  stomach  of 
mucus  and  fermentative  products  is  the  direct  way  out  of  the  diffi- 
culty. Modern  times  have  afforded  us  superior  advantages  in  this 
respect,  and  there  is  now  little  difficulty  in  curing  uncomplicated 
cases  of  chronic  gastritis  even  of  long  standing.  If  complications 
exist  they  should  be  removed  if  possible  and  the  problem  then  be- 
comes as  clear  as  ever.  The  tenacious  mucus,  which  serves  as  a 
nidus  for  fermentative  products,  must  be  removed  and  the  interior 
of  the  stomach  kept  cleansed,  when  a  little  other  treatment,  except  a 
proper  regimen,  is  required.  We  possess  two  effective  measures  for 
this  purpose,  which  may  be  employed  singly  or  combined.  I  refer 
to  (1)  lavage  and  (2)  disinfection  and  cleansing  with  hydrozone. 

Lavage  is  an  efficient  means  of  cleansing  the  stomachal  cavity.  It 
is  performed  by  the  aid  of  an  elongated,  soft-rubber  tube,  to  one  end 
of  which  is  attached  a  glass  funnel.  Dealers  in  rubber  goods  furnish 
these  tubes  upon  application,  with  open  lower  end,  fenestrated  sides, 
and  raised  ridge  to  indicate  the  point  of  sufficient  introduction,  this 
being  at  the  lips  when  the  tube  is  in  situ.  In  order  to  introduce  it 
it  is  first  coiled  in  a  bowl  containing  warm  or  cold  milk,  according 
to  the  preference  of  the  patient,  and  the  fenestrated  extremity  is 


LAVAOE:    IRRIGATION  AND  SIPHON  AOK. 


then  passed  over  the  protruded  tongue  into  the  lower  part  of  the 
pharynx,  the  patient  assisting  its  onward  motion  by  efforts  at  swal- 
lowing accompanied  by  deep  inspirations.  Steady  pushing  will  now 
carry  the  instrument  into  the  oesophagus  and  it  will  then  glide  easily 
along  until  the  lower  end  passes  into  the  stomach,  when  the  funnel 
should  be  affixed.  It  may  be  necessary  for  the  physician  to  assist 


DISEASES  OF  THE  STOMACH.  387 

in  the  introduction  for  four  or  five  times,  after  which  the  patient  will 
be  able  to  attend  to  it  for  himself.  After  initiation  the  patient  holds 
the  funnel  in  his  left  hand  and  a  flask  of  the  fluid  to  be  used  in  the 
right,  fills  the  funnel  and  raises  it  above  his  head,  when  the  contents 
flow  into  the  stomach  (irrigation).  The  funnel  is  immediately  after- 
ward depressed  below  the  level  of  the  stomach,  when  the  principle 
of  siphonage  operates  to  withdraw  the  liquid  contents,  which  are  al- 
lowed to  flow  into  a  pail  placed  between  the  patient's  feet.  Lavage 
is  therefore  divided  into  two  stages,  viz.:  Irrigation  and  siphonage. 

Reflex  irritation,  such  as  nausea  and  vomiting  with  dyspnoea, 
which  may  attend  the  beginning  of  this  measure,  may  usually  be 
quieted  by  the  administration  of  a  single  dose  of  twenty  grains  of 
bromide  of  potassium  taken  an  hour  or  so  beforehand.  Where  the 
presence  of  the  tube  in  the  stomach  provokes  vomiting,  the  imme- 
diate introduction  of  a  little  fluid  to  remove  the  gastric  wall  from 
contact  with  the  extremity  of  the  tube  will  be  sufficient,  usually,  to 
quiet  the  reflex. 

The  amount  of  fluid  to  be  used  at  a  time  should  be  small  at  first, 
as  vomiting  is  easily  excited;  and  until  the  stomach  has  become  used 
to  the  maneuver  a  pint  will  be  sufficient.  As  treatment  progresses, 
however,  one,  two  or  three  quarts  may  be  used  at  a  time  without 
inconvenience,  treatment  to  be  repeated  each  morning  before  eating. 

The  solutions  should  be  warm  (98.5°  F.  or  thereabout)  and  may 
consist  of  simple  alkaline  drenches,  a  drachm  and  a  half  of  Glauber's 
salts  to  a  quart  of  water  constituting  a  popular  fluid  for  the  purpose. 
I  find  weak  solutions  of  asepsin  excellent  and  have  used  boracic  acid 
as  a  medicament  with  satisfaction.  Long-standing  cases  of  uncom- 
plicated chronic  gastritis  recover  completely  in  a  few  months  on  this 
treatment  without  the  assistance  of  other  measures  except  proper 
attention  to  dieting.  Mucus  and  retained  fermentative  elements  and 
products  are  thus  removed  and  the  mucous  membrane  is  aroused  to 
normal  action,  the  hypersetnia  subsiding  and  the  irritated  surface 
returning  to  a  healthy  condition. 

The  introduction  of  hydrozone  as  a  remedy  in  this  condition  was 
another  innovation  of  remarkable  value.  A  drachm  of  Marchand's 
hydrozone  added  to  four  ounces  of  boiled  water  and  drank  while  the 
stomach  is  empty  exerts  a  powerful  influence  in  dissolving  and  re- 
moving the  tenacious  mucus,  destroying  microbic  elements  of  fermen- 
tation and  stimulating  normal  action  in  the  diseased  mucous  struc- 
ture. The  best  results  folloAv  its  use  in  the  morning  before  break- 
fast, the  patient  taking  it  while  in  bed  and  remaining  on  the  left  side 
for  ten  minutes  before  rising.  It  may  be  taken  oftener,  but  once  a 
day  will  suffice,  and  it  may  be  advantageously  used  in  this  manner 
after  the  practice  of  lavage. 


388  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

The  hydrozone  may  produce  acrid  sensations  in  the  throat  and 
stomach  at  first  and  the  patient  may  complain  of  an  unpleasant  taste 
following  its  action;  but  as  the  irritated  gastric  surface  becomes 
toned  under  its  influence  thia  will  pass  away  and  sensitiveness  to  its 
effect  will  subside.  Where  there  seems  to  be  very  much  objection 
the  amount  may  be  considerably  lessened  until  the  patient  becomes 
accustomed  to  its  action  and  until  the  sensitive  mucous  surface  be- 
comes more  tolerant. 

The  important  step  in  chronic  gastric  catarrh  (as  iu  catarrh  of  all 
other  mucous  cavities)  is  the  cleansing  of  the  part  from  ropy  mucus, 
which  clogs  the  glandular  organs  and  serves  as  a  nidus  for  the  opera- 
tion of  agents  of  fermentation.  Glycozone  may  sometimes  be  pre- 
ferred, glycerine  possessing  individual  virtue  in  certain  cases  of  indi- 
gestion from  fermentation. 

With  attention  to  such  details  as  have  already  been  described, 
little  more  is  necessary  in  the  treatment  of  this  disease.  Some  ad- 
vise, in  the  absence  or  lack  of  the  normal  amount  of  hydrochloric 
acid,  that  this  drug  be  supplied,  in  suitable  doses,  well  diluted  with 
water.  Benefit  may  sometimes  follow  this  measure,  but  with  the 
removal  of  morbid  accumulations  a  normal  amount  of  hydrochloric 
acid  will  soon  be  supplied  by  nature — all  that  will  be  required  for 
the  limited  diet  which  the  nature  of  the  case  demands.  The  effi- 
ciency of  bitter  tonics  is  doubtful  when  they  are  administered  upon 
"general  principles,"  though  some  of  them  may  specifically  improve 
the  recuperative  forces  of  the  gastric  mucous  membrane  and  aid  in 
a  restoration  of  normal  conditions.  I  believe  berberis  aquifolium  to 
be  one  of  these,  its  beneficial  influence  in  catarrh  of  mucous  mem- 
branes generally  adapting  it  here,  while  it  is  an  acknowledged  stom- 
achic of  superior  virtue.  Ten-drop  doses  of  a  reliable  fluid  prepara- 
tion repeated  thrice  daily  will  often  assist  materially  in  restoring  a 
normal  condition  of  the  gastric  mucous  membrane  and  digestive 
glands,  aiding  digestion,  banishing  boulimia  and  promoting  a  normal 
appetite. 

When  catarrhal  accumulation  is  a  marked  feature  and  there  is  a 
yellow  coating  on  the  tongue  persistently  bichromate  of  potassium  in 
minute  doses  (two  or  three  grains  of  the  3x)  repeated  three  or  four 
times  daily  will  assist  the  local  treatment.  Nux  vomica  may  relieve 
some  of  the  local  unpleasantness,  and  there  are  those  who  assert  that 
it  specifically  ameliorates  the  catarrhal  condition.  The  specific  indi- 
cations need  not  be  referred  to  here,  but  the  dose  should  be  minute. 
Hydrastis,  pulsatilla,  robinia,  antimouinm  crudem,  bismuth  (both 
the  subnitrate  and  liquor)  and  many  other  remedies  have  their 
advocates. 

In  anaemic  persons,  where  catarrhal  tendencies  are  strong,  calcium 


DISEASES  OF  THE  STOMACH.  389 

phos.  3x  in  two-  or  three-grain  doses  repeated  three  or  four  times  a 
day  will  lessen  the  ropy  secretion  and  lessen  anaemic  tendencies. 
Protonuclein  is  a  drug  that  promises  much  as  a  restorative  here. 

Where  chronic  gastritis  attends  malarial  cachexia  that  group  of 
remedies  which  tend  toward  lessening  the  pressure  in  the  radicles  of 
the  portal  vein  will  be  efficient  in  relieving  the  congestion  of  the  gas- 
tric mucosa.  Of  the  four  principal  ones  of  these — polymnia,  ceano- 
thus,  carduus  and  grindelia  squarrossa — grindelia  squarrosa  is  iny 
favorite.  Improvement  in  digestion  under  favorable  circumstances 
almost  invariably  follows  its  use.  From  five  to  ten  drops  of  a  sat- 
urated tincture  of  the  genuine  plant  administered  in  a  swallow  of 
water  and  repeated  three  times  a  day  insure  marked  benefit  within 
a  few  days.  Chionanthus  in  ten-drop  doses  may  be  advantageously 
combined  with  it  in  most  cases,  especially  where  icteric  symptoms 
are  present. 

Sometimes  we  may  be  urged  to  administer  agents  for  the  relief 
of  cardiac  palpitation  and  associate  gastric  distress.  Cactus  grandi- 
florus  and  pulsatilla  possess  an  established  reputation  and  they  will 
occasionally  answer  us  well.  The  best  remedy  I  have  ever  tried, 
however,  is  a  saturated  tincture  of  aploppapus  laricifolius  in  from 
two-  to  ten-drop  doses,  one  or  two  doses  at  a  time  being  sufficient 
for  temporary  relief.  It  calms  erethism  of  the  sympathetic  nervous 
system,  promotes  rest,  strengthens  cardiac  action,  lessens  pain,  re- 
lieves praecordial  oppression,  favors  evacuation  of  the  bowels  and 
aids  digestion.  Minute  doses  of  aconite  and  rhus  tox.  are  not  to  be 
despised  for  this  condition,  that  reliable  gastric  sedative  combina- 
tion being  very  serviceable,  even  sometimes  in  chronic  irritation. 

Where  constipation  is  present  enemata  will  be  found  preferable 
to  laxative  medicines,  the  salt-water  galvanic  enema  being  an  excel- 
lent aid  in  stubborn  cases,  it  not  being  necessary  to  repeat  it  more 
than  once  or  twice  a  week.  The  positive  pole  should  here  be  applied 
with  a  moistened  sponge  over  the  epigastrium. 

Local  applications  over  the  epigastrium  are  sometimes  of  excel- 
lent service  and  in  intractable  cases  should  be  tried.  The  compound 
tar  plaster  of  our  forefathers,  worn  over  the  epigastrium  until  pustu- 
lation  begins,  to  be  removed  for  a  few  days  and  its  use  repeated 
again  and  again  to  perpetuate  a  superficial  irritation,  has  many  able 
advocates  even  at  the  present  day;  and  I  have  known  it  to  effect 
most  excellent  results.  A  vinegar  pack  or  girdle,  worn  upon  the  epi- 
gastrium, is  hardly  less  effective.  Equal  parts  of  vinegar  and  water 
may  be  employed  to  moisten  an  epigastric  pad,  which  should  be 
wrung  as  dry  as  possible  two  or  three  times  within  the  twenty-four 
hours  and  worn  constantly,  the  clothing  being  protected  by  an  oiled 
silk  covering. 


390  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

As  the  disease  is  a  long  time  in  becoming  established,  it  should 
be  expected  that  several  months  will  be  required  to  overcome  it. 

DILATATION  OF  THE  STOMACH. 

Synonym. — Gastrectasis. 

Definition. — Permanent  enlargement  of  the  cavity  of  the  stom- 
ach due  to  stretching  of  its  walls,  with  degeneration  of  the  muscular 
coat. 

Etiology. — Gastrectasis  may  occur  in  an  acute  or  chronic  form, 
acute  gastrectasis,  however,  being  very  rare.  The  acute  form  may 
occur  as  the  result  of  the  ingestion  of  an  enormous  quantity  of  ali- 
ment at  a  single  meal,  paralytic  dilatation  resulting.  The  usual  form 
of  dilatation  occurs  from  causes  which  bring  about  a  gradual  enlarge- 
ment of  the  stomach,  the  most  common  being  pyloric  stenosis. 
Pyloric  stenosis  may  result  from  thickening  of  the  walls  of  the  pyloris 
as  the  result  of  acute  or  chronic  inflammation,  cancerous  infiltration, 
non-malignant  ulceration  or  fibroid  induration  of  the  pylorus.  Other 
cases  of  gastrectasis  may  be  due  to  atony  of  the  muscular  walls  from 
habitual  over-distention  of  that  organ,  as  is  common  with  gourmands" 
and  beer-drinkers.  Paralysis  of  the  nerve-supply,  attended  by  im- 
pairment of  normal  peristalsis,  is  another  cause  of  this  condition, 
this  sometimes  occurring  from  suppurations  about  the  stomach,  such 
as  empyaema  or  suppurative  pericarditis;  and  parenchymatous  degen- 
eration, occurring  as  a  result  of  scarlet  fever,  may  impair  permanently 
the  tonicity  of  the  gastric  muscles.  A  somewhat  rare  cause  of  this 
condition  may  be  hernia,  which  operates  by  dragging  the  organ 
downward,  adhesions  also  sometimes  acting  in  a  similar  manner. 
Middle-aged  or  elderly  persons  are  most  liable  to  be  affected,  though 
dilatation  of  the  stomach  may  occur  in  children,  associated  with 
rickets. 

Pathology. — The  amount  and  character  of  the  dilatation  differ 
materially  in  different  cases.  Sometimes  the  enlargement  is  regular, 

the  walls  being  evenly  stretched  so  that  the 
\     cardiac  extremity  is  carried  toward  the  left 
}  and  upward,  this  usually  being  the  case  when 
/    there    is  pyloric  stenosis  without  localized 
/     weakness  of  any  particular  part  of  the  organ. 
In   other    cases    there    may   be  some   local 
DILATATION  OF  THE  STOMACH  WITH   weakness,  due  to  ulceration  or  erosion  of  the 

PTTLOBIC  STENOSIS.  .  -i       i 

Dotted  line  represents  dilatation.      Wall,  Circumscribed  pat  'llCS  yielding  to  foi'lll 

pouches  or  diverticula.  Stenosis  is  at  first  followed  by  hypertrophy 
of  the  walls  of  the  stomach,  this  after  ward  be  ing  attended  by  atrophy 
and  dilatation.  The  muscles  may  now  be  so  thinned  and  stretched 


DISEASES  OF  THE  STOMACH.  391 

as  to  be  scarcely  discernible,  and  fatty  degeneration  of  its  fibers  may 
attend.  Muscular  atrophy  is  most  marked  where  atony  of  the  mus- 
cular wall  arises  independently  of  stenosis.  Here  the  rugse  of  the 
mucous  membrane  may  have  disappeared  and  the  covering  become 
pale  and  atrophied. 

Symptoms. — Indigestion  and  gastric  discomfort  are  the  first 
symptoms  noted.  In  acute  dilatation  there  is  sharp  pain  in  the  epi- 
gastric region,  tenderness  upon  pressure  and  prsecordial  oppression 
with  sensations  of  fullness.  As  these  symptoms  subside  indications 
of  chronic  dilatation  manifest  themselves.  Vomiting  at  intervals  of 
enormous  quantities  (from  one  to  three  gallons)  of  food  and  liquid  is 
the  most  usual  symptom  of  this  condition.  The  intervals  may  be 
two  or  three  days  in  length,  the  material  ejected  usually  being  the 
major  portion  of  what  has  been  ingested  during  such  periods.  The 
vomitus  consists  of  mucus  and  remnants  of  food,  all  of  which  has 
undergone  decomposition,  the  mass  exhaling  a  foetid  odor,  presenting 
a  frothy,  yeasty  appearance  and  being  acid  in  reaction.  Various 
resisting  substances,  such  as  cherry  stones,  grape  seeds,  etc.,  may 
be  found.  Upon  microscopic  examination  abundance  of  the  yeast 
plant  and  sarcina  ventriculi  will  be  found  and  also  various  bacteria. 
Lactic  and  butyric  acids  with  various  gases  may  be  present;  and 
hydrochloric  acid  may  or  may  not  be  found,  it  sometimes  existing  in 
excess. 

Pyrosis,  eructations  of  foetid  and  acrid  material,  heartburn  with 
epigastric  weight  and  pain  and  other  gastric  disturbances  are  almost 
constantly  manifest.  Emaciation  progresses,  nutrition  suffering 
much,  the  skin  becoming  harsh  and  dry,  the  bowels  constipated 
and  the  urine  scanty.  Muscular  cramps,  sometimes  amounting  to 
spasms,  usually  attend  aggravated  cases,  the  muscles  of  the  calves, 
hands  and  arms  being  most  affected.  The  appetite  may  be  vora- 
cious or  there  may  be  anorexia.  Usually  there  is  a  voracious 
appetite. 

Upon  inspection  an  eminence  will  be  observed  just  above  the 
umbilical  region  with  a  depression  in  the  epigastrium,  which  may 
become  filled  after  taking  meals  or  draughts  of  fluid.  Sometimes 
the  stomach  may  be  outlined  by  palpation,  the  prominence  of  the 
pylorus  and  gastric  peristaltic  action  being  detected.  Percussion 
may  reveal  a  tympanitic  sound  over  the  epigastric  region  when  the 
stomach  is  empty  and  an  area  of  dullness  when  it  is  distended,  over 
an  abnormally  large  space.  Auscultation  may  reveal  succussion  or 
splashing  of  fluids  when  the  abdomen  is  shaken,  and  the  falling  of 
fluids  into  the  gastric  cavity  when  these  are  swallowed. 

Diagnosis. — The  habitual  vomiting  of  large  quantities  of  decom- 
posed food  and  mucus  at  two-  or  three-day  intervals,  with  emaciation 


392  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

and  gastric  discomfort,  is  sufficient  to  establish  a  diagnosis.  Inspec- 
tion of  the  material  ejected  may  assist  in  doubtful  cases. 

Prognosis. — Therapeutic  resources  are  usually  futile  in  the 
management  of  such  cases.  Where  pyloric  stenosis  is  the  perpetu- 
ating cause  a  cure  may  follow  longitudinal  incision  and  transverse 
stitching  at  the  point  of  narrowing,  this  serving  to  widen  the  open- 
ing and  afford  a  ready  passage  for  the  food.  When  an  abstemious 
regimen  is  followed,  dilatation  due  to  simple  stenosis  may  not  inter- 
fere greatly  with  average  longevity. 

Treatment. — Lavage,  with  warm  water  and  asepsin,  is  an  im- 
portant part  of  treatment.  This  should  be  repeated  sufficiently 
often  to  prevent  decomposition  of  food  and  avert  large  accumula- 
tions, thus  providing  against  disteution  and  weight.  Instead  of  asep- 
sin hydrozone  may  be  used  to  medicate  the  cleansing  fluid. 

Strychnia,  nux  vomica,  galvanism  and  faradistn  are  all  recom- 
mended to  stimulate  contraction  of  the  relaxed  muscular  walls. 
Where  the  mucous  membrane  is  atrophied  berberis  aquifolium  is 
worthy  of  lengthened  trial. 

The  food  should  be  taken  in  small  quantities  and  be  of  fluid  and 
concentrated  form.  Not  more  than  six  ounces  of  drink  should  be 
allowed  at  one  meal,  and  in  bad  cases  no  drinks  at  all  should  be 
allowed  at  meal-time,  a  tumblerful  of  hot  water  being  taken  half  an 
hour  before  eating  that  it  may  pass  into  the  duodenum  and  be 
absorbed  before  the  food  is  introduced  into  the  stomach.  Ferment- 
able foods,  such  as  starchy  articles  and  sugars  and  fruits  which  con- 
tain much  water  and  vegetable  acids  (which  are  apt  to  disagree), 
should  be  avoided.  Peptonized  milk,  scraped  beef,  lean  beef  free 
from  coarse  fibrin,  fresh  vegetables  and  dry  bread  comprise  the  kind 
of  food  to  be  taken.  Some  prefer  a  dry  diet,  only  enough  being 
allowed  to  meet  the  most  urgent  demands  of  the  body.  Fats  should 
be  discarded. 

PEPTIC  ULCER. 

Synonyms. — Round  Ulcer;  Chronic  Gastric  Ulcer. 

Definition. — An  ulcer,  usually  single  though  sometimes  multi- 
ple, which  arises  from  the  action  of  the  gastric  juice  upon  a  limited 
region  of  the  gastric  or  duodenal  mucous  membrane,  in  which  nutri- 
tional disturbance  has  lessened  the  resistant  capacity  of  the  tissues 
involved. 

Etiology. — More  than  twice  as  many  cases  occur  among  women  as 
among  men,  this  being  due,  possibly,  to  the  fact  that  women  are  more 
apt  to  follow  occupations  necessitating  a  stooping  posture  whereby 
there  is  crowding  of  the  short  ribs  against  the  pyloric  extremity  of 


DISEASES  OF  THE  STOMACH.  393 

the  stomach.  Possibly  the  habit  of  wearing  corsets  and  of  lacing 
may  bear  somewhat  upon  the  etiology.  The  most  active  period  of 
life — between  the  ages  of  fourteen  and  thirty — is  the  time  of  greatest 
liability,  though  it  may  occur  in  the  new-born  babe  and  in  the  octo- 
genarian. Anything  which  tends  to  cause  thrombus  of  the  gastric 
vessels  predisposes  to  it.  It  is  also  liable  to  occur  in  chronic  gas- 
tritis, hepatic  and  renal  cirrhosis  and  other  conditions  involving 
obstruction  of  the  circulation  in  the  gastric  mucous  membrane. 
Anaemia  and  chlorosis  are  constitutional  states  in  which  there  is  a 
tendency  to  it.  A  habitual  stooping  posture  has  already  been  re- 
ferred to  as  a  probable  predisposing  cause,  and  it  may  be  mentioned 
iii  this  connection  that  it  is  more  frequent  among  milliners,  seam- 
stresses, shoemakers  and  others  whose  employment  calls  much  of 
the  time  for  a  bending  position. 

Pathology, — The  ulcer  occurs  upon  the  posterior  wall  of  the 
stomach  near  the  pylorus,  in  a  large  majority  of  cases,  though  it  may 
develop  upon  the  anterior  wall.  Occasionally  a  peptic  ulcer  may 
develop  in  the  duodenum  and  manifest  the  characteristics  of  a  per- 
forating ulcer  of  the  stomach.  Peptic  ulcers  vary  in  size  from  half 
an  inch  to  two  inches  in  diameter  and  are  usually  round,  though 
they  may  be  oblong  or  oval,  and,  when  formed  of  several  small  ones, 
irregular  in  contour.  They  begin  in  the  mucous 
membrane  and  excavate  a  sharply  defined  border, 
the  opening  appearing,  upon  autopsy,  as  though 
punched  through  the  mucous  membrane  with  a 
sharp  instrument.  As  the  ulceration  grows  deeper 
the  circles  grow  less  regular  and  smaller,  the  exca- 
vation assuming  a  funnel  shape,  until,  when  the 
peritoneum  is  reached,  the  opening  may  be  a  mere 
», perforation.  point.  During  the  perforating  process  there  is  no 

b,  mucous  membrane.  , .         •     /•  . «  u  in  i  e  it 

active  inflammatory  action,,  though  the  edges  of  the 
ulcer  may  sometimes  be  thickened  and  indurated,  while  in  other 
cases  the  surrounding  tissues  may  be  normal.  Usually  the  entire 
mucous  membrane  of  the  stomach  is  involved  in  a  chronic  catarrhal 
condition,  though  sometimes  the  catarrh  is  confined  to  the  vicinity 
of  the  ulcer. 

Perforation  occurs  in  only  about  one-eighth  of  the  cases  affected 
with  round  ulcer,  recuperative  processes  often  accomplishing  a  res- 
toration of  the  breach  of  continuity,  a  permanent  cicatrix  remaining. 
The  cicatrix  sometimes  contracts  so  as  to  obstruct  the  pyloric  open- 
ing or  cause  other  deformity  of  the  stomach. 

The  ulcerative  process  may  meet  with  important  bloodvessels  in 
its  course,  and  profuse  hematemesis  be  the  result  of  their  destruc- 
tion. As  the  ulcer  approaches  the  peritoneal  surface  of  the  stomach 


394  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

a  circumscribed  peritonitis  is  liable  to  be  excited  in  the  neighbor- 
hood and  adhesions  may  take  place  between  the  part  and  such  an  ad- 
joining viscus  as  the  liver,  pancreas,  mesentery  or  spleen,  and  the 
fatal  results  of  perforation  thus  be  stayed. 

Various  deviations  from  the  usual  course  of  the  ulceration  may 
attend.  The  base  of  the  ulcer  may  be  covered  with  a  mass  of  black 
blood,  which  adheres  to  the  surface,  or  there  maybe  petechial  extrav- 
asations around  the  ulcerated  space  or  suppuration  in  the  coats  of 
the  stomach,  with  resultant  phlebitis.  In  other  cases  villous  growths 
may  spring  up  about  the  base  of  the  ulcer,  upon  the  surrounding 
mucous  membrane. 

Though  the  posterior  wall  of  the  stomach  is  the  usual  location  of 
the  ulcer,  it  sometimes  attacks  the  anterior  wall,  and  perforation  is 
much  more  liable  to  occur  in  this  instance,  as  there  is  less  probability 
of  adhesions. 

Perforation  is  attended  by  escape  of  some  of  the  contents  of  the 
stomach  into  the  peritoneal  cavity,  with  rapidly  succeeding  peritoni- 
tis. If  adhesions  prevent  the  escape  of  the  contents  local  peritoni- 
tis, suppuration  and  burrowing  abscesses  may  follow,  with  fistulous 
openings  into  the  pleural  sac,  lung,  intestine,  gall-bladder  or  other 
viscus. 

Symptoms. — The  symptoms  in  the  beginning  are  often  obscure. 
Indigestion,  attended  by  burning,  gnawing  sensations,  pyrosis  and 
gastric  catarrh,  with  jaundice  and  even  nausea  and  vomiting,  may  be 
developed.  Pain  soon  becomes  a  noticeable  symptom  and  grows 
more  and  more  obstinate.  Though  dull  at  first  it  soon  becomes  lan- 
cinating and  attends  the  period  of  digestion,  coming  on  soon  after 
eating  and  continuing  until  the  stomach  is  empty;  though  sometimes 
it  does  not  appear  until  an  hour  or  so  after  food  is  taken.  After 
a  time  there  develops  a  pain  in  the  dorsal  region,  which  is  said  to  be 
peculiar  to  this  disease  in  that  it  is  constant,  is  located  in  the  eighth 
or  ninth  dorsal  vertebra,  and  does  not  come  on  for  several  months 
after  the  epigastric  pain  becomes  established.  The  epigastric  pain 
may  not  be  severe  at  first,  but  it  soon  becomes  excruciating  during 
digestion,  and  is  often  relieved  by  change  of  position,  pressure  some- 
times affording  comfort — the  patient  finding  relief  by  lying  across  a 
chair  or  with  the  epigastrium  upon  a  hard  pillow  flat  on  the  floor. 
The  pain  may  be  paroxysmal,  being  very  severe  for  weeks,  then  dis- 
appearing for  a  time,  with  another  protracted  period  of  intense  suf- 
fering. Tenderness  on  pressure  is  usually  present,  the  patient  wear- 
ing the  clothing  loose  and  objecting  to  anything  snug  about  the 
waist.  The  point  of  tenderness  is  usually  small,  not  larger  than  a 
silver  dollar,  and  is  felt  on  deep  pressure  just  above  the  umbilicus 


DISEASES  OF  THE  STOMACH.  395 

(in  the  majority  of  instances)  and  over  the  eighth  or  ninth  dorsal 
vertebra. 

Vomiting  is  another  prominent  symptom,  the  rejection  of  food 
occurring  in  a  large  number  of  cases.  This  occurs  after  the  pain  has 
become  severe,  the  rejection  of  the  food  being  usually  followed  by 
alleviation.  The  food  is  mixed  with  gastric  juice  of  highly  acid 
nature,  with  more  or  less  bile,  biliary  material  becoming  quite  plen- 
tiful as  the  disease  progresses.  Sometimes  a  patient  will  vomit  after 
each  meal,  sometimes  once  a  day,  while  in  other  instances  two  or 
three  days  may  elapse  between  attacks. 

Hsematemesis  is  another  symptom  which  occurs  frequently, 
though  not  invariably.  It  appears  in  serious  form  after  the  ulcera- 
tion  has  advanced  so  as  to  destroy  the  walls  of  arterial  twigs,  slight 
capillary  hemorrhage  not  attracting  much  attention  previously,  the 
blood  then  passing  away  with  the  stools.  When  an  important  vessel 
is  disintegrated,  however,  a  large  quantity  of  clotted  blood,  of  bright 
red  color,  is  vomited,  the  patient  previously  experiencing  a  sensation 
of  faintness ;  and  even  collapse  may  attend,  the  first  hemorrhage 
sometimes  proving  fatal.  Repeated  hemorrhages  are  followed  by 
anaemia,  debility  and  cachetic  symptoms,  the  features  becoming 
drawn  and  the  skin  sometimes  assuming  an  icteric  or  waxy  hue. 

Where  diarrhoea  exists,  as  is  sometimes  the  case,  the  stools  are 
mixed  with  a  dark,  tarry  material  consisting  of  decomposed  blood, 
to  which  the  term  "melsena"  is  applied. 

Diagnosis.— -The  diagnosis  is  sometimes  obscure.  Gastralgia 
may  be  readily  confounded  with  this  disease  where  hemorrhage  is 
not  present,  as  dyspeptic  symptoms,  vomiting,  pain  and  even  tender- 
ness on  pressure  may  be  present  in  both.  Where  hseinatemesis 
occurs  there  can  be  no  possibility  of  an  error  in  this  respect,  as  it  is 
absent  in  gastralgia.  In  cancer  there  is  lack  or  absence  of  free 
hydrochloric  acid  in  the  stomach,  while  in  peptic  ulcer  there  is  an 
excess  of  this.  The  epigastric  tumor  of  cancer  is  absent  in  ulcer 
and  pain  is  much  aggravated  by  eating,  while  pain  of  cancer  is  sel- 
dom thus  provoked.  Cancer  of  the  stomach  is  most  apt  to  occur  in 
those  of  middle  or  past-middle  life,  while  perforating  ulcer  is  more 
apt  to  attack  younger  persons.  The  hemorrhage  of  cancer  also  differs  in 
character,  the  blood  being  of  coffee-ground  appearance,  while  in  peptic 
ulcer  it  is  bright  red  if  the  clots  be  broken.  The  cachexia  of  cancer  is 
more  marked  than  that  of  peptic  ulcer  early,  and  the  vomiting  does 
not  always  occur  with  immediate  reference  to  the  presence  of  food  in 
the  stomach.  It  is  impossible  to  differentiate  between  a  duodenal 
and  gastric  peptic  ulcer  during  life. 

Prognosis. — It  is  asserted  by  good  authority  that  more  than 
half  the  cases  of  peptic  ulcer  recover.  Some  terminate  fatally  in  a 


39G  DISEASES  OF  THE  DIGESTIVE  OKGAKS. 

few  weeks,  while  others  may  continue  many  months  to  finally  recover 
or  afterward  terminate  fatally.  Those  of  feeble  constitution  are  less 
apt  to  resist  the  inroads  of  the  disease,  senile  subjects  and  delicate 
women  being  the  most  unfortunate  victims. 

Treatment. — Congestive  conditions — hyperaemia — of  the  portal 
circulation  should  be  corrected  as  much  as  possible  by  the  use  of 
such  agents  as  grindelia  squarrosa,  polymnia,  carduus  marianus  and 
ceanothus.  These  agents  may  assist  in  removing  blood-pressure  upon 
thrombi  and  restoring  a  normal  circulation  in  the  gastric  mucous 
membrane. 

As  curative  agents  we  must  think  of  those  remedies  which  exert 
a  plastic  influence  upon  the  diseased  structures.  Such  special  reme- 
dies as  kali  bichromicum  3x,  argentum  nit.  6x  and  nitrate  of  uranium  3x 
are  appropriate  members  of  this  group.  Berberis  aquifolium  is  an 
excellent  remedy  as  in  all  other  cases  of  chronic  ulceration;  and  at 
the  same  time  it  is  an  excellent  restorative  of  the  general  system,  pro- 
moting digestion,  assimilation  and  blood-making. 

I  have  had  excellent  results  from  three-grain  doses  of  kali  bi- 
chromicum 3x  repeated  every  four  hours  during  the  day.  It  certainly 
exerts  a  healing  influence  in  such  cases,  and  if  used  faithfully  before 
too  much  progress  has  been  made  I  believe  it  will  cure. 

The  Schuessler  remedies  promise  better  results  than  ordinary 
treatment  in  this  affection  and  should  receive  the  practitioner's 
respectful  attention  in  stubborn  cases.  The  following  experiences 
are  from  a  paper  on  "Biochemistry,"  read  before  the  Oregon  State 
Medical  Association  September  23,  1898,  by  A.  A.  Leonard,  M.  D., 
and  will  apply  here: 

"Case  III. — Miss  H.,  aet.  19,  German  descent;  domestic;  family 
history  good;  personal  history,  healthy  up  to  a  year  previous  to  con- 
sulting me,  when  she  began  to  run  down,  had  indigestion  and  lost 
flesh  and  strength.  On  previous  New  Year's  Day  (this  was  in  March) 
she  had  vomited,  she  said,  about  a  quart  of  blood.  This,  of  course, 
was  an  exaggeration.  Since  that  time  she  had  suffered  pain  after 
eating,  often  vomited  her  meals,  had  acid  eructations  and  continually 
lost  strength.  Her  symptoms  at  the  time  of  calling  were  the  same, 
except  that  that  morning  she  had  thrown  up  a  quantity  of  blood,  and 
was  in  consequence  very  weak.  I  diagnosed  gastric  ulcer. 

"For  the  three  prominent  symptoms — hemorrhage,  acid  indiges- 
tion and  anaemia — I  gave  ferrum  phos.,  natrum  phos.  and  calcium 
phos.  She  had  no  other  remedies  except  rest  and  regulated  diet. 
There  was  no  more  haematemesia  and  after  a  few  days  I  left  off  the 
ferrum  phos.  and  continued  the  natrum  phos.  and  calc.  phos.  for  two 
weeks  longer.  The  result  was  a  surprise  to  me,  for  she  gained  in 
every  way  beyond  my  expectations.  In  fact,  inside  of  two  months 


DISEASES  OF  THE  STOMACH.  397 

she  was  the  picture  of  health,  her  appetite  excellent  and  she  was 
stronger  and  healthier  in  every  way  than  she  had  been  for  several 
years.  The  cure  was  permanent,  for  I  heard  from  her  a  year  and  a 
half  later  and  she  was  still  in  good  health. 

"Case  IV. — Miss  K.  D.,  aet.  20,  American.  Occupation,  teacher. 
History  of  stomach-pain,  occasional  gnawing  in  stomach  with  some 
soreness  for  the  past  year.  Sent  for  me  Christmas  Day,  '97.  I 
found  her  suffering  with  hsematemesis,  which  was  somewhat  alarm- 
ing. The  vomiting  had  come  on  at  night  and  had  continued  at  inter- 
vals during  the  day,  until  she  was  quite  weak. 

"I  diagnosed  gastric  ulcer,  and  to  meet  the  first  indication,  the 
arrest  of  the  hemorrhage,  I  gave  her  glonoin  and  hyoscyamine  suffi- 
cient to  keep  the  skin  flushed  for  the  first  twenty-four  hours.  I  might 
have  stopped  the  hemorrhage  with  ferrum  phos.,  perhaps,  but  hardly 
dared  to  risk  it.  She  was  put  to  bed  with  strict  injunctions  to  stay 
there  and  remain  as  quiet  as  possible,  and  was  allowed  atablespoon- 
ful  of  milk  every  two  hours  for  the  first  day,  gradually  increased  as 
the  symptoms  abated.  After  the  first  day  I  put  her  on  natrum  phos. 
and  calc.  phos.,  the  same  as  Case  III.  She  steadily  improved  from 
the  first  and  rapidly  recovered.  She  was  kept  on  these  remedies  for 
about  four  weeks.  I  have  recently  heard  from  her  and  she  has  had 
no  relapse,  and  is  now  in  robust  health." 

Subnitrate  of  bismuth  exerts  a  local  influence  that  is  worthy  of 
consideration,  though  little  permanent  benefit  can  be  expected  from 
it  as  a  rule. 

Minute  doses  of  aconite  and  rhus.  tox.  may  be  tried  where  the 
vomiting  is  intractable,  arid  in  event  of  the  failure  of  this  measure 
resort  may  be  had  to  lavage. 

In  incurable  cases  opiates  may  be  required  to  alleviate  the  pain. 
Hemorrhage  should  be  treated  by  the  recumbent  posture  and  the 
administration  of  ten-drop  doses  of  erigeron  canadense,  hypodermic 
injections  of  ergotine  in  two-  or  three-grain  doses  or  other  astringents. 

The  patient  should  remain  quiet  in  bed  to  insure  rest  and  a  re- 
cunibent  position,  and  the  diet  should  be  liquid,  bland  in  character 
and  should  be  administered  in  small  quantities,  in  order  to  avoid 
distension  of  the  stomach  and  risk  of  perforation.  After  hsematem- 
esis  the  stomach  should  be  allowed  to  remain  quiet  for  a  time,  and 
food  should  be  introduced  into  the  rectum  in  the  form  of  nutrient 
enemata.  When  food  is  taken  into  the  stomach,  a  milk  diet  is  appro- 
priate, though  care  must  be  observed  that  it  be  not  taken  so  as  to 
result  in  the  formation  of  firm  curds.  On  this  account  Horlick's 
malted  milk  may  be  preferable,  though  the  addition  of  a  tablespoon- 
ful  of  lime-water  to  a  pint  of  raw  milk  will  provide  against  this  to 
considerable  extent.  Where  acceptable,  butter-milk  or  koumiss  will 


398  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

be  appropriate  for  nourishment,  and  all  danger  of  curds  will  be 
avoided.  Almost  any  form  of  liquid  diet  which  will  not  irritate  deli- 
cate structures  will  be  proper,  and  rotation  among  several  kinds  will 
encourage  the  patient  to  take  sufficient  for  sustenance.  After  hem- 
orrhage the  quantity  taken  at  a  time  should  be  limited  to  a  few  tea- 
spoonfuls,  larger  and  larger  quantities  being  given  gradually  until 
three  or  four  ounces  are  administered  at  a  time  as  bleeding  ceases. 
Milk,  beef-juice,  broths,  malt  extracts  and  other  fluid  foods  may 
be  allowed  until  convalescence  is  announced,  when  scraped  beef, 
chicken,  fresh  sweetbread,  tapioca  and  rice  pudding,  e.tc.,  may  be 
allowed  in  small  quantities,  the  patient  remaining  quiet  in  bed  for 
another  month,  in  order  to  allow  the  new  structure  to  acquire  appro- 
priate strength.  A  recent  addition  to  the  materia  medica,  and  at 
the  same  time  an  excellent  nutrient,  is  preserved  beef's  blood— 
bovinine.  Thirty  drops  of  this  in  a  cup  of  hot  water,  repeated  every 
three  or  four  hours,  may  afford  good  results. 

CANCER  OF  THE  STOMACH. 

Etiology. — Age  and  location  are  probably  prominent  among  the 
etiological  factors  of  gastric  cancer.  As  in  cancer  in  other  locations, 
those  past  middle  life  are  most  liable  to  this  kind,  about  one-third 
of  all  cases  of  primary  cancer  having  their  origin  in  the  stomach. 
Osier  states  that  cancer  of  the  stomach  is  only  second  in  frequency 
to  that  of  uterine  cancer.  It  is  more  frequent  in  males  than  females, 
in  the  ratio  of  about  five  to  four.  Local  irritation,  doubtless,  con- 
tributes to  the  predisposition  of  this  part  to  malignant  disease,  the 
almost  constant  disturbance  which  it  undergoes  as  the  active  organ 
in  receiving  and  reducing  food  for  digestion  probably  being  contrib- 
utory, while  accidental  irritation  from  indigestible  and  acrid  mater- 
ials which  are  swallowed,  and  the  pernicious  habit  of  prescribing 
irritating  cathartics  so  fashionable  among  a  large  class  of  physicians, 
assists  in  contributing  to  the  cancerous  tendency.  Long-con- 
tinued irritation  of  such  kind  may  finally  give  rise  to  the  develop- 
ment of  the  new  growth,  the  disease  being  rare  in  children  and 
uncommon  before  the  age  of  forty. 

The  favorite  seat  of  gastric  cancer  is  the  pylorus  and  when  located 
here  the  upper  portion  of  the  duodenum  also  is  usually  involved.  The 
next  point  in  frequency  of  attack  is  the  cardiac  extremity  arid  lesser 
curvature,  the  lower  portion  of  the  oasophagus  then  usually  being 
implicated.  Cancer  of  the  stomach  is  a  common  disease  in  tfyis  coun- 
try, and  should  be  suspected  in  all  cases  of  gastric  trouble  attended 
by  rapidly  encroaching  debility  and  emaciation. 

Family  tendency  is  somewhat  marked,  something  like  one-seventh 


DISEASES  OF  THE  STOMACH.  399 

of  the  cases  occurring  probably  belonging  to  this  class.  It  is  con- 
sidered, by  good  authority,  doubttul  that  depressing  emotions,  mode 
of  life  or  previous  disease  exert  any  influence  in  the  etiology  of  the 
affection.  Various  popular  beliefs  exist  that  cancer  is  due  to  the 
influence  of  certain  foods.  For  example,  many  believe  that  the  eat- 
ing of  tomatoes  predisposes  to  cancer,  a  proposition  which  seems 
ridiculous  from  a  scientific  point  of  view. 

Pathology, — While  the  pylorus  is  the  most  frequent  seat  of 
cancer  and  the  cardiac  extremity  next,  the  curvatures,  fundus  and 
body  may  all  be  affected  by  the  primary  growth.  There  is  a  differ- 
ence of  opinion  among  medical  authors  as  to  which  form  is  most 
common,  some  asserting  that  scirrhous  cancer  is  most  frequent  and 
others  claiming  the  supremacy  for  epithelioid.  My  own  experience 
leads  me  to  favor  the  opinion  that  scirrhous  is  most  often  found, 
although  I  have  no  statistics  to  offer.  Epithelioma  occurs  fre- 
quently, and  all  forms  may  become  colloid  or  gelatiniform  in  char- 
acter during  their  progress.  In  many  instances  the  morbid  growth 
may  be  a  combination  of  several  varieties. 

Scirrkosis  of  the  stomach  develops  in  the  submucous  structure, 
small,  grayish  nodules  enveloping  the  extremities  of  off-shoots  of  the 
gastric  tubules  which  have  pushed  their  way  into  the  submucous  tis- 
sue, the  character  of  the  growth  then  being,  in  reality,  epithelial, 
though  the  fibrous  stroma  is  greatly  in  excess  of  the  cell-element 
As  the  disease  progresses  the  fibrous  structure  encroaches  upon  the 
mucous  membrane,  puckering  it  into  nodules  and  pushing  them  out- 
ward into  the  cavity  of  the  stomach  in  polypoid  forms,  rapid  increase 
of  new  tissue  thickening  the  pyloric  wall  and  narrowing  the  lumen, 
the  growth  extending  along  the  greater  and  lesser  curvatures  toward 
the  dilated  portion  of  the  stomach.  The  muscular  and  areolar  lay- 
ers become  fused  into  an  indistinguishable  mass  after  a  time,  the 
surface  of  a  fresh  cut  presenting  a  whitish,  glistening  appearance, 
with  pearly  settings,  the  individuality  of  the  mucous,  submucous  and 
muscular  layers  being  entirely  lost.  As  the  pylorus  becomes  oc- 
cluded the  unaffected  portion  of  the  stomach  becomes  dilated,  though 
sometimes  its  walls  are  shriveled  and  contracted  with  leathery  thick- 
ening of  the  entire  structure.  Chronic  gastritis  may  arise  from 
pressure  of  the  indurated  part  against  the  unaffected  mucous  mem- 
brane and  the  usual  appearance  of  such  condition  may  be  manifested 
beyond  the  cancerous  mass.  As  ulceration  develops  there  is  liability 
to  perforation  of  the  gastric  wall,  the  opening  sometimes  entering 
the  peritoneal  cavity,  sometimes  penetrating  the  duodenum  or  other 
neighboring  organ  and  sometimes  even  forming  an  external  opening 
through  the  anterior  wall  of  the  abdomen.  Secondary  cancerous 
deposits  are  common,  the  liver  being  most  frequently  involved,  then 


400 


DISEASES  OF  THE  DIGESTIVE  ORGANS. 


the  lymphatic  glands  and  neighboring  intestines,  especially  the  rec- 
tum. The  kidneys,  pancreas,  spleen,  bladder  and  other  abdominal 
and  pelvic  organs,  as  well  as  those  of  the  thorax,  are  liable  to  be 
secondarily  involved. 

Encephaloid  cancer  begins  in  the  submucous  tissue,  though  the 
nodules  are  much  softer,  the  stroma  being  less  abundant  and  the 
cells  more  numerous.  It  develops  more  rapidly  than  scirrhus  and  is 
more  vascular,  large  fleshy  spongy  excrescenses  projecting  into  the 
gastric  cavity. 

Colloid  cancer  of  the  stomach  is  rare.  It  is  said  to  begin  in  the 
glandular  structure  of  the  gastric  wall,  though  t  invades  all  the  coats 
with  great  rapidity  and  also  involves  neighboring  organs  in  the  same 
manner.  It  does  not  appear  in  the  form  of  nodules  but  as  an  irreg- 
ular mass  of  gummy,  glistening  material  inclosed  in  large  alveoli. 
The  entire  structure  of  the  stomach  is  much  thickened,  and  on  the 
inner  surface  there  are  closely-set  cavities  of  honey-comb  appearance 
marking  empty  alveoli,  which  have  discharged  their  contents. 

Symptoms. — Rapid  loss  of  flesh  and  strength  with  dyspeptic 
symptoms  is  sufficient  to  warrant  suspicion  of  cancer  of  the  stomach. 
Sometimes  the  gastric  symptoms  are  more  marked  and  there  will  be 
anorexia,  nausea  and  vomiting  and  pain  after  eating.  Anaemia  of  a 
peculiar  character  soon  develops,  the  skin  presenting  a  peculiar  sal- 
low, clayey  or  waxy  appearance  and  being  leathery  and  inelastic  to 

the  feel.  The  pulse  is  increased 
in  frequency  and  becomes  small 
and  feeble,  and  these  symptoms 
are  steadily  aggravated  in  spite 
of  treatment.  In  colloid  can- 
cer, where  the  entire  stomach 
is  sometimes  involved,  there 
may  be  tumultuous  peristaltic 
action  of  that  organ  at  times, 
though  this  is  not  common. 
Where  the  pylorus  is  mostly 
affected  a  tumor  may  soon  be 
felt  just  above  the  umbilicus, 
which  is  hard,  firm  and  immov- 


CANCKR  OF  THE  STOMACH. 

a,  pylorus. 

b,  duodenum . 

c,  p»Bgage  through  cancerous  growth. 

d,  cut  surface  of  cancf  r. 

e,  diseased  mucous  mei.ibrane. 

f,  normal  mucous  membrane  wrinkled  transversely  able  and  \\hicll   USUally  pulsates 
from  cancerous  contraction.  ,  . ,  .   .  •,  ,    , 

from  the  impact  of  the  abdomi- 
nal aorta.  When  the  cardiac  extremity  is  the  part  involved,  the 
tumor  is  not  perceptible  upon  palpation. 

Dyspeptic  symptoms  are  so  common  in  other  cases  that  they  are 
not  highly  suggestive  of  cancer,  aud  as  cancer  patients  are  liable  to 
be  dyspeptic  subjects  long  before  the  malignant  disease  develops, 


DISEASES  OF  THE  STOMACH.  401 

these  do  not  attract  much  attention  until  they  become  extreme. 
Vomiting,  however,  soon  draws  attention  to  the  gravity  of  the  case. 
This  may  occur  only  occasionally  at  first,  perhaps  not  oftener  than 
once  every  three  or  four  days,  but  it  usually  increases  rapidly  in  fre- 
quency arid  after  a  few  weeks  may  recur  several  times  a  day.  It  is 
most  apt  to  be  severe  when  the  malignant  growth  is  about  the  ori- 
fices, vomiting  occurring  soon  after  eating  when  the  cardiac  orifice  is 
affected  and  after  a  considerable  interval  where  the  growth  is  about 
the  pylorus.  The  vomiting  consists  of  food  and  mucus  mixed  with 
various  acids  and  exhaling  a  sour  and  foetid  odor.  After  ulceration 
of  the  morbid  growth  begins  hsematemesis  is  not  uncommon,  the 
blood  being  mixed  with  other  material  or  so  altered  by  the  secretions 
as  to  present  a  dark  brown  or  black  appearance,  then  termed 
"coffee-ground"  vomit.  The  yeast  plant,  various  bacteria  and  sarcinse 
ventriculi  are  present,  though  not  so  common  as  in  gastrectasis. 

Much  stress  is  placed  by  many  diagnosticians  upon  the  absence 
of  free  hydrochloric  acid  from  the  gastric  secretions.  To  determine 
this  administer  a  test  meal,  consisting  of  a  breakfast  of  a  Vienna  roll 
with  a  cup  of  tea  without  sugar  or  milk,  and  after  an  hour  remove 
some  of  the  contents  with  a  stomach-tube  for  examination.  The 
method  of  Gunsburg  for  detecting  hydrochloric  acid  is  simple  and 
effective:  Mix  phloroglucin  two  parts,  vanillin  one  part  and  alcohol 
thirty  parts.  Add  a  drop  of  this  to  a  drop  of  the  gastric  contents 
(filtered)  on  a  porcelain  plate  and  evaporate  to  dryness,  watching 
the  reaction.  If  free  hydrochloric  or  other  mineral  acid  be  present 
a  handsome  rose-red  color  begins  to  appear  at  the  edges.  As  hydro- 
chloric acid  may  be  present  under  other  circumstances  as,  for  instance, 
when  there  is  atrophy  of  the  gastric  tubules,  this  symptom  cannot  be 
considered  diagnostic  and  may  only  be  taken  as  corroborative  when 
other  indications  of  cancer  attend. 

Pain  is  a  common  symptom  of  gastric  cancer,  though  quite  a  num- 
ber of  cases  run  their  course  without — unless  it  be  that  which  attends 
peritonitis  after  perforation  has  occurred.  The  pain  varies  in  its 
situation,  though  it  is  most  commonly  in  the  epigastrium.  Some- 
times it  is  almost  confined  in  the  dorsal  region,  sometimes  it  is  felt 
most  under  the  scapulae,  and  occasionly  it  lingers  about  the  loins.  It 
is  burning  and  dragging  in  character,  hardly  ever  being  lancinating 
or  excruciating,  as  in  peptic  ulcer. 

Dropsical  symptoms  are  likely  to  appear  during  the  advanced 
stage  of  gastric  ulcer.  They  are  first  observed  about  the  ankles  and 
legs,  these  becoming  swollen  and  cedematous,  especially  after  the 
patient  has  been  upon  his  feet  for  a  few  hours  in  the  morning.  As 
further  progress  is  made,  ascites  or  anasarca  may  arise. 

The  wasting  of  flesh  affects  the  heart  muscle  and  its  debility  is 

27 


402  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

marked  during  the  last  stages  of  the  disease,  the  pulse  being  weak 
and  rapid;  and  it  may  seem,  from  the  acceleration  of  the  pulse  and 
hot  skin,  that  febrile  symptoms  are  present.  Indeed,  this  may  some- 
times be  the  case,  chills  and  fever,  with  elevation  of  temperature  to 
102° — 104°  F.  (followed  by  profuse  sweats)  arising  temporarily, 
though  the  temperature  is  usually  normal  or  subnormal.  The  febrile 
paroxysms  are  probably  due  to  suppurative  action  and  are  not  com- 
mon among  the  early  developments  of  the  disease. 

As  secondary  cancer  involves  other  organs  a  marked  modifica- 
tion of  the  symptoms  may  result.  Cancer  of  the  liver  may  give  rise 
to  jaundice,  with  enlargement,  pain  and  tenderness  in  the  right  hypo- 
chondrium.  Ascites  may  now  be  a  direct  result  of  this  condition 
through  obstruction  of  the  portal  circulation.  Extension  of  the  can- 
cerous infiltration  to  the  peritoneum  may  give  rise  to  widely  diffused 
pain  over  the  abdominal  region,  and  obstruction  of  the  vena  cava 
ascendens  results  in  dilatation  of  the  superficial  epigastric  and  other 
subcutaneous  abdominal  veins. 

Diagnosis. — In  ordinary  cases,  especially  where  the  pylorus  is 
the  seat  of  the  affection,  the  diagnosis  is  comparatively  easy.  The 
gastric  disturbance  with  vomiting,  the  rapid  loss  of  flesh  and  strength, 
the  epigastric  tumor  readily  felt  through  the  attenuated  abdominal 
wall  as  a  hard,  immovable  body  (pulsating  with  the  aortic  impact), 
with  the  constant,  burning  pain,  can  hardly  be  mistaken  for  symp- 
toms of  any  other  disease.  In  other  cases,  however,  the  tumor  may 
be  so  located  that  it  cannot  be  discovered  by  palpation,  the  gastric 
disturbance  may  be  slight  and  the  constitutional  symptoms  may 
readily  be  taken  for  those  of  pernicious  anaemia.  In  other  cases  the 
constitutional  symptoms  may  not  appear  prominently  until  near  the 
last  and  the  local  symptoms  may  be  mistaken  for  those  of  chronic 
gastritis  or  gastrectasis — until  the  "coffee-ground"  vomit  appears. 
Secondary  affection  of  adjacent  organs  early  may  also  obscure  the 
diagnosis. 

Prognosis. — Invariably  unfavorable.  The  most  that  can  be 
promised  is  temporary  palliation  of  the  pain  and  other  unpleasant 
symptoms.  The  average  duration  of  cancer  is  two  years,  though  as 
the  disease  will  have  progressed  considerably  before  a  diagnosis  can 
be  made  it  is  estimated  that  few  survive  more  than  a  year  after 
that  time.  Some  cases  run  a  rapid  course,  a  fatal  termination 
being  reached  in  from  three  to  six  mouths.  A  cure  is  barely 
possible. 

Treatment. — In  pyloric  cancer  with  stenosis  lavage  may  afford 
some  relief  from  the  gastric  unpleasantness  by  neutralizing  accumu- 
lated fermentative  products  and  removing  superfluous  mucus.  Hydro- 
zone  or  asepsin  may  be  employed  for  this  purpose  as  directed  under 


DISEASES  OF  THE  STOMACH.  403 

chronic  gastritis.  As  there  is  some  danger  of  perforating  the  weak- 
ened wall  of  the  stomach,  discretion  should  be  observed  in  the  use 
of  the  stomach  tube,  hydrozone  alone  sufficing  to  remove  the  mucus 
without  lavage.  Cundurango  assists  in  relieving  the  pain  and  vomit- 
ing in  some  cases  and  is  always  worthy  of  trial.  Echinacea  is  almost 
a  specific  in  the  pain  of  cancer  and  should  be  tried  here  early,  though 
it  may  not  be  reliable  to  quiet  the  vomiting.  Bovinine  is  another 
agent  that  is  worthy  of  trial,  as  its  nutrient  qualities  are  combined 
with  excellent  anodyne  and  calmative  properties.  Some  cases  may 
justify  abdominal  section  and  resection  of  the  pylorus,  though  a 
fatal  result  may  be  expected  within  a  few  days  in  most  instances. 
The  use  of  opiates  freely  is  fully  justifiable  during  the  last  stage, 
though  echiuacea  is  more  reliable  as  a  pain  reliever. 

One  or  two  drops  of  carbolic  acid  mixed  with  glycerine  and  diluted 
with  water  will  often  prove  exceptionally  valuable  in  controlling  the 
vomiting. 

Chelidonium  has  recently  promised  much — curatively — in  this  dis- 
ease and  it  will  probably  act  best  in  combination  with  echinacea. 
The  dose  may  vary  from  fifteen  to  twenty  drops  of  the  specific  medi- 
cine. Another  measure  promising  much  is  that  of  Cutter — a  strict 
diet  of  chopped  beef  and  hot  water,  without  tea,  coffee  or  milk. 

A  still  later  acquisition  to  the  list  of  curatives  in  cancer  is  euca- 
lyptus, which  might  be  tried  here,  an  approximate  dose  being  ten 
drops  of  a  saturated  tincture  of  the  fresh  leaves. 

The  dietetic  treatment  of  cancer  of  the  stomach  is  very  important. 
Solid  food,  after  the  disease  has  progressed  appreciably,  should  be 
discarded  altogether  for  fear  of  perforation  or  hemorrhage.  Even 
such  liquids  as  require  stomach  digestion  ought  to  be  largely  avoided 
and  reliance  for  nourishment  had  upon  liquid  predigested  food,  such 
as  beef  peptonoids  or  pancreatinized  or  peptonized  milk.  However, 
as  these  may  become  distasteful  after  protracted  use  without  varia- 
tion, rice-water  and  various  vegetable  and  animal  soups  may  be  alter- 
nated to  vary  the  routine.  If  chopped-beef  diet  is  to  be  employed 
it  should  be  begun  early  and  the  beef  should  be  minced  exceedingly 
fine.  Black  tea  and  coffee  without  milk  may  be  allowed  sparingly. 
If  the  patient  desires  a  small  amount  of  claret  or  port  wine  may  be 
taken,  unless  it  provokes  gastric  discomfort. 

NON-MALIGNANT  TUMORS  OF  THE  STOMACH. 

THESE  growths  are  seldom  found,  and  when  present  are  small 
and  cause  little  trouble.  Polypi  are  the  most  common  variety. 
They  are  usually  multiple  and  may  be  very  numerous,  as  many  as  a 
hundred  and  twenty  having  been  reported  in  a  single  case.  They 


404  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

consist  of  hypertrophied  mucous  follicles,  which  become  peduncu- 
lated.  Fibromata  and  lipomata  are  seldom  met  with.  Lymphomata 
may  develop  during  the  progress  of  leukaemia.  Foreign  bodies  in 
the  stomach  may  he  mistaken  for  tumors  when  palpation  alone  is 
relied  upon. 

H^MATEMESIS. 

Synonym.  — Gastorrhagia. 

Etiology. — Many  causes  conspire  to  bring  about  vomiting  of 
blood,  though  the  most  common  one  is  rupture  of  the  bloodvessels 
of  the  stomach.  The  capillaries  of  the  vessels  are  most  frequently 
ruptured,  though  bleeding  often  occurs  from  rupture  of  branches  of 
the  gastric  artery.  The  exciting  causes  may  be  divided  into: 

Traumatic,  produced  mechanically — from  perforation  by  a  stom- 
ach-tube, by  hard  food,  by  irritant  chemicals  or  by  external  violence. 

Diseases  of  the  blood,  as  occurs  in  such  infectious  diseases  as  yel- 
low fever,  malaria,  typhoid  and  typhus,  etc. 

Congestion  of  the  gastric  mucous  membrane,  as  occurs  in  acute 
gastritis  and  vicarious  menstruation;  in  active  congestion  and  the 
passive  congestion  which  attends  obstruction  of  the  portal  circulation, 
as  in  hepatic  cirrhosis,  thrombosis  of  the  portal  vein  and  other 
causes  of  retardation  of  the  flow  of  blood  through  the  liver  or  along 
the  branches  of  the  portal  vein,  such  as  pressure  from  abdominal 
tumors,  etc.  Hepatic  or  pulmonary  diseases  obstructing  the  return 
of  venous  blood  to  the  right  auricle  may  also  operate  in  this  direc- 
tion through  backward  pressure.  Similar  effects  may  arise  from 
omental  hernia  when  this  exerts  a  dragging  influence  upon  the 
stomach. 

Local  diseases  of  the  stomach  may  be  attended  by  ulcerative 
abrasion  of  the  gastric  vessels,  as  in  ulceration  from  chronic  catarrh, 
peptic  ulcer  or  cancer.  Varicose  conditions  of  the  gastric  veins  or 
aneurism  of  a  branch  of  the  gastric  or  splenic  artery  may  result  in 
rupture,  or  such  an  accident  may  occur  during  violent  retching  or 
vomiting. 

Nervous  conditions,  such  as  progressive  paralysis  of  the  insane, 
epilepsy  or  hysteria,  the  character  of  the  accident  then  sometimes 
beiug  inexplicable.  Sometimes  the  blood  may  be  swallowed  as  a 
result  of  bleeding  in  the  pharynx,  nasal  passages,  larynx  or  resoph- 
agus  and  afterward  vomited.  Malingerers  and  hysterical  persons 
sometimes  swallow  the  blood  of  animals  and  afterward  vomit  it  up 
for  mercenary  purposes  or  to  excite  sympathy. 

Pathology, — A  variety  of  conditions  may  be  found  after  death 
from  haematemesis.  In  hsemateniesis  from  cirrhosis  of  the  liver  no 


DISEASES  OF  THE  STOMACH.  405 

local  lesion  can  be  found,  the  blood  having  probably  passed  into  the 
stomach  by  diapedesis  from  the  gastric  capillaries.  Or  there  may 
be  a  rupture  of  a  submucous  vein  and  the  erosion  of  the  mucous 
membrane  escape  notice  on  account  of  the  minute  size  and  post-mor- 
tem changes.  Miliary  aneurisms  may  communicate  with  the  cavity 
of  the  stomach  by  pin-hole  perforations  and  post-mortem  appear- 
ance afford  no  explanation  of  the  morbid  condition.  When  the  hem- 
orrhage results  from  portal  obstruction  no  lesion  is  observable, 
except  that  the  mucous  membrane  is  smooth  and  pale  in  appearance. 
Intestinal  ulcers  tell  their  own  stories. 

Symptoms. — Hemorrhage  and  later  anaemia  are  the  prominent 
symptoms.  There  are  cases,  however,  where  neither  of  these  symp- 
toms is  manifest,  either  because  the  quantity  of  blood  is  so  small 
that  it  does  not  cause  emesis  or  because  the  amount  is  so  large  that 
immediately  fatal  results  occur  before  it  becomes  developed.  The 
blood  may  be  ejected  by  regurgitation  or  by  severe  vomiting  and  by 
all  grades  between.  The  amount  may  vary  from  a  few  streaks  in  the 
vomited  material  to  as  much  as  three  or  four  pounds  in  twenty-four 
hours.  In  nearly  all  cases  a  portion  of  the  blood  may  pass  into  the 
intestines  and  in  some  cases  the  entire  amount  will  be  discharged 
this  way,  the  stools  then  presenting  the  dark  tarry  appearance 
observed  in  hemorrhage  from  the  upper  intestinal  canal.  The  secre- 
tions of  the  stomach  destroy  the  fresh  appearance  of  blood  in  the 
stomach  after  a  little  while,  and  when  it  remains  in  the  stomach  for 
a  while  it  is  dark  and  grumous  (like  coffee-grounds)  and  the  clots,  if 
any  appear,  are  dark  and  irregular  when  vomited;  but  if  ejected 
soon  after  leaving  the  bloodvessels  its  appearance  is  little  altered. 
The  anaemia  varies  in  degree,  according  to  the  amount  of  blood  lost. 

Diagnosis. — Care  must  be  observed  not  to  confound  haematem- 
esis  with  haemoptysis.  Attention  to  the  following  points  will  afford 
valuable  assistance  in  this  direction:  In  haematemesis  the  blood  is 
expelled  by  vomiting  and  if  there  be  any  cough  present  it  occurs  after 
vomiting,  while  in  haemoptysis  the  cough  occurs  in  the  beginning  and  if 
vomiting  comes  on  afterward  it  is  excited  by  the  coughing.  In  haema- 
temesis the  blood  is  liable  to  be  mixed  with  particles  of  food,  while 
in  haemoptysis  the  blood  is  clear  and  frothy  and  rales  may  afterward 
be  heard  over  the  lungs.  In  haematemesis  the  blood  is  expelled  in 
quantities  with  complete  intervals,  while  in  haemoptysis  there  is 
repeated  and  frequent  expectoration  of  blood  with  cough  after  the 
principal  amount  has  been  expelled.  Physical  examination  should 
be  made  in  all  cases  where  there  is  any  doubt,  auscultation  of  the 
chest  assisting  in  determining  any  question  in  the  matter. 

Prognosis. — Fatal  result  may  attend  aneurism  or  the  rupture 
of  a  large  vein  in  the  gastric  walls,  but  other  gastric  hemorrhages 


406  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

are  seldom  fatal.  Hemorrhages  from  cirrhosis  of  the  liver  or  other 
portal  obstruction  are  more  dangerous  than  those  from  ulcer  or 
cancer. 

Treatment. — Absolute  rest  in  the  recumbent  position  is  an 
important  element  of  treatment.  All  food  by  the  mouth  should  be 
discontinued,  the  patient  being  supported  by  rectal  alimentation,  and 
thirst  should  be  relieved  by  sucking  small  pieces  of  ice,  drinking 
being  avoided.  Ergotin  and  morphia  may  be  given  hypodermically 
to  constringe  the  bloodvessels  and  promote  rest  from  peristalsis. 
In  extreme  cases  brandy  per  rectum  will  assist  against  collapse. 
After  the  active  symptoms  subside  food  should  be  liquid  in  form  and 
only  small  quantities  should  be  taken  at  a  time  until  eroded  vessels 
have  had  time  to  heal.  When  portal  obstruction  is  the  cause  of  the 
hemorrhage,  efforts  should  be  made  to  relieve  the  condition,  fullness 
of  the  abdominal  capillaries  being  restrained  in  some  measure  by 
such  remedies  as  polymnia,  ceanothus  and  carduus  mariauus.  In 
malarial  haematemesis  grindelia  squarrosa  would  be  preferable. 
Ulceration  of  the  stomach  should  be  met  by  appropriate  treatment. 

FUNCTIONAL  GASTRIC  DYSPEPSIA. 

Synonym. — Nervous  Dyspepsia. 

Definition. — Indigestion  in  which  there  is  no  observable  organic 
lesion  to  account  for  the  disturbance. 

Etiology. — The  causes  of  this  form  of  indigestion  are  numerous, 
and  usually  of  reflex  character.  Nervous  dyspepsia  is  a  common 
accompaniment  of  uterine  lacerations  and  almost  a  constant  symp- 
tom— in  greater  or  less  degree — of  such  rectal  irritation  as  that 
attending  hemorrhoids,  rectal  pockets  and  papillae.  It  may  be  brought 
on  by  severe  mental  occupation  associated  with  sedentary  habits  or 
by  depressing  influences  continued  for  a  lengthened  period.  Rheum- 
atic affection  of  the  muscular  walls  of  the  stomach  may  be  attended 
by  difficult  and  painful  digestion,  it  then  being  termed  gastralgia  or 
gastrodynia.  Impairment  of  the  functions  of  the  secreting  glands 
of  the  stomach  may  also  arise,  subacidity  or  hyperacidity  being  the 
condition.  Anaemia  and  neurastheeuia  are  commonly  attended  by 
functional  dyspepsia,  and  malaria  may  be  an  important  factor. 

Pathology. — Careful  examination  will  determine  the  absence  of 
auy  structural  disease;  though  digestion  is  attended  by  various 
kinds  of  discomfort  there  is  lack  of  any  local  structural  change  to 
account  for  it.  Often  the  irritation  is  at  a  remote  distance  from  the 
stomach,  and  so  far  as  its  structural  character  is  concerned  of  a  tri- 
fling nature,  but  such  as  to  constantly  tease  the  terminals  of  sympa- 
thetic nerves. 


DISEASES  OF  THE  STOMACH.  407 

Symptoms. — The  symptoms  will  vary  according  to  the  special 
character  of  the  affection,  though  there  is  much  in  common  with  them 
all.  Pain  of  burning  character  often  attends,  though  instead  of 
scalding  sensations  in  the  stomach  there  may  be  sharp,  lancinating 
distress  of  neuralgic  character.  Sometimes  there  is  aching  in  the 
epigastric  region  with  sensation  as  though  there  was  a  hardened  ball 
in  the  stomach,  and  again  the  painful  sensation  may  be  that  as  of  a 
gnawing  in  the  part.  An  unpleasant  sensation  of  fullness  in  the 
epigastric  region  follows  eating  in  most  cases,  accompanied  by  prse- 
cordial  distress  and  dyspnoea.  Eructations  of  food  and  acid  material 
are  common,  and  peristaltic  unrest,  attended  by  gurgling,  borboryg- 
mus  and  abdominal  pain,  is  a  frequent  symptom.  In  many  instances 
there  is  pectoral  and  cardiac  pain  during  digestion.  Irritability  of 
temper  and  melancholia  commonly  attend.  Vomiting  attends  some 
cases,  the  food  being  ejected  from  the  stomach  soon  after  meals. 

Diagnosis. — The  diagnosis  of  nervous  dyspepsia  from  organic 
affections  of  the  stomach  is  not  always  easy.  In  functional  dyspep- 
sia, however,  it  should  be  recollected  that  though  much  distress  may 
attend  the  process  of  digestion,  it  is  completed  during  the  physio- 
logical time-limit.  Seven  hours  after  the  iugestion  of  food  the 
stomach  should  be  found  empty.  A  careful  inspection  of  the  con- 
tents of  the  stomach  during  digestion  may  throw  much  light  upon 
the  character  of  the  affection  as  regards  hyperacidity,  subacidity,  etc. 

Prognosis. — Every  case  of  functional  dyspepsia  ought  to  be 
cured,  as  there  is  usually  a  removable  cause,  and  it  remains  for  the 
physician  to  search  this  out  and  correct  it. 

Treatment. — The  practitioner  should  inquire  carefully  into  the 
habits  of  his  patient  to  determine  whether  or  not  the  condition  depends 
upon  some  indiscretion  of  diet,  mental  taxation,  sexual  excess  or  abuse 
or  other  avoidable  cause.  If  such  exist  a  cure  depends  much  upon  a 
radical  and  permanent  reform  in  this  direction.  The  diet  should  be 
carefully  selected  with  reference  to  the  avoidance  of  articles  that  are 
known  to  disagree;  fats,  starches,  sugars,  tea  and  coffee  being 
avoided,  and  the  general  health  attended  to  by  judicious  application 
of  exercise,  genial  companionship  and  pleasant  surroundings.  Mala- 
rious conditions  attended  by  dyspepsia  will  demand  the  employment 
of  grindelia  squarrosa,  polymnia,  chionanthus  or  carduus  marianus;  and 
constipation  must  be  properly  treated,  the  use  of  copious  enemata  of 
salt  water  being  efficacious  for  this  purpose,  daily  irrigation  of  the 
rectum  and  colon  being  sufficient  to  afford  relief.  A  careful  exam- 
ination of  the  orifices  of  the  body  should  be  instituted  to  determine 
their  condition  and  enable  the  practitioner  to  decide  as  to  the  neces- 
sity of  surgical  interference.  Lacerated  cervix,  rectal  pockets,  papillae, 
hemorrhoids,  etc.,  should  be  suspected  (if  not  inducing  the  condition) 


408  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

whenever  present  The  vomiting  of  food,  which  attends  some  cases 
of  the  kind,  will  almost  always  disappear  upon  the  removal  of  rectal 
or  uterine  irritation,  of  which  gastric  symptoms  are  but  reflexes. 

Sometimes  functional  dyspepsia  depends  upon  the  presence  of 
prostatic  irritation  and  demands  the  judicious  employment  of  galvan- 
ism, with  the  aid  of  such  sexual  tonics  as  saw  palmetto,  salix  nigra  and 
viburnum. 

Berberis  aquifolium  and  piper  methysticum  are  especially  valuable 
as  encouragers  of  the  digestive  functions.  The  dose  of  either  may 
vary  from  ten  to  fifteen  drops  of  the  specific  medicine  or  some  other 
reliable  preparation  administered  in  a  little  water  before  each  meal 
and  at  bedtime. 

Self-massage  immediately  upon  rising  in  the  morning  is  an  excel- 
lent practice  for  nervous  dyspeptics.  All  the  muscles  of  the  body 
should  be  thoroughly  rubbed  and  kneaded,  to  be  afterward  well 
pounded  with  the  fists,  the  epigastric  region  receiving  special  atten- 
tion of  this  kind.  The  effect  of  such  treatment  upon  all  the  organs 
of  digestion  is  excellent,  and  superior  to  that  of  drugs  alone. 

Praecordial  oppression  yields  to  small  doses  of  aploppapus  lar., 
one  or  two  being  taken  soon  after  eating  (five  or  ten  drops  of  the 
tincture)  an  hour  or  more  apart. 

Painful  conditions  of  the  stomach  may  require  the  use  of  caulo~ 
phyllin  (3x  trituration),  a  decoction  of  cimicifuga,  specific  colocynth, 
dioscorea  or  other  especially  demanded  drug. 

HYPERSECRETION  AND  HYPERACIDITY. 

NORMALLY,  the  gastric  juice  is  secreted  only  during  the  process 
of  digestion.  When  its  secretion  occurs  between  such  times,  it  con- 
stitutes hypersecretion.  It  is  usually  associated  with  some  nervous 
disorder,  such  as  locomotor  ataxia  or  neurasthenia.  Hyperacidity 
is  a  more  common  condition  and  is  an  aggravating  attendant  of  gas- 
tric ulcer. 

Symptoms. — There  is  burning,  gnawing  pain  in  the  stomach 
and  substernal  region  with  acid  eructations  which  set  the  teeth  on 
edge.  In  aggravated  cases  vomiting  of  gastric  juice  may  occur. 
All  these  symptoms  are  ameliorated  by  eating.  The  eructations  and 
sour  risings  of  chronic  gastritis,  dilatation,  etc.,  occur  after  eating, 
while  in  this  case  they  occur  during  fasting,  and  there  is  no  admix- 
ture of  food  in  the  eructations  as  in  those  cases.  Starchy  food  is 
digested  slowly. 

Diagnosis. — A  test-breakfast  of  a  Vienna  roll  and  a  cup  of  tea 
without  milk  or  sugar  may  be  ordered  and  an  hour  afterward  some 
of  the  contents  removed  through  a  stomach-tube  may  be  subjected  to 


DISEASES  OF  THE   STOMACH.  409 

quantitive  analysis  to  determine  the  question  of  hyperacidity.  If 
there  be  hypersecretion  the  presence  of  hydrochloric  acid  in  the 
stomach  during  fasting  hours  will  determine  the  matter. 

Treatment. — In  hypersecretiou  lavage  with  weak  alkaline  solu- 
tions should  be  practiced  every  day,  the  irrigation  to  occur  before 
the  principal  meal.  Minute  doses  oijaborandi,  hydrastis  or  menisper- 
mum  canadense  should  be  administered  for  their  tonic  influence  upon 
the  gastric  tubules.  Where  hyperacidity  is  present  an  alkaline  treat- 
ment should  be  administered,  and  a  diet  consisting  principally  of 
proteids,  such  as  lean  meat,  largely  adhered  to,  the  patient  also 
taking  plenty  of  out-door  exercise  and  occupying  the  mind  with  active 
diversion.  Berberis  aquifolium  is  an  excellent  remedy  where  there  is 
excessive  activity  of  the  gastric  tubules,  the  dose  ranging  from  five  to 
ten  drops  of  a  reliable  fluid  extract  three  or  four  times  daily.  Cac- 
tus grandiflorus  is  another  remedy  which  sometimes  proves  useful 
in  such  cases,  the  dose  being  from  three  to  five  drops  three  or  four 
times  daily. 

GASTRALGIA. 

Synonym. — Gastrodynia. 

Definition. — Pain  in  the  stomach  without  organic  disease  or 
disturbance  of  digestion. 

Etiology. — Gastralgia  is  due  to  a  variety  of  causes.  It  may  be 
neuralgic  or  muscular,  many  cases  being  due  to  the  fact  that  the  sub- 
ject is  prone  to  attacks  of  muscular  rheumatism,  the  disease  fre- 
quently involving  the  muscular  walls  of  the  stomach.  In  other  cases 
it  may  occur  as  the  leading  symptom  of  an  attack  of  malaria,  the  paiii 
coming  on  periodically  and  being  amenable  to  the  curative  action  of 
antiperiodics.  In  other  cases  it  may  be  purely  reflex,  depending 
upon  uterine  irritation,  such  as  laceration  of  the  cervix  uteri,  in 
which  case  it  is  likely  to  appear  coincideutally  with  the  menstrual 
period.  Or,  rectal  irritation  may  give  rise  to  it  through  reflex 
action,  aggravation  of  the  local  irritation  being  transferred  to  the 
stomach  instead  of  being  appreciated  at  the  actual  point  of  disturb- 
ance. Some  persons  of  gouty  tendency  are  liable  to  such  attacks, 
and  lead  poisoning  may  manifest  itself  in  severe  paroxysms  of  gas- 
trodynia.  The  abuse  of  narcotics,  such  as  tobacco  and  tea,  may*  lead 
to  attacks  of  this  kind. 

Symptoms. — Sudden  and  excruciating  pain  in  the  epigastric 
region  is  the  initial  symptom  in  the  majority  of  cases,  though  there 
may  be  premonitory  loss  of  appetite,  nausea  and  other  gastric 
unpleasantness  for  a  few  hours  prior  to  the  attack.  The  pain  may 
be  burning,  boring,  griping  or  aching  in  character  and  it  may  radiate 


410  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

to  the  back  and  around  the  waist,  the  paiu  being  constant  or  inter- 
mittent. Eating  sometimes  relieves  and  hardly  ever  aggravates, 
unless  it  be  in  gastralgia  of  rheumatic  type,  when  eating  may  pro- 
voke aggravation.  Pressure  may  aggravate  if  firm,  though  light 
pressure  may  afford  comfort.  Subjects  of  gastralgia  are  usually  per- 
sons of  highly  nervous  temperament. 

Diagnosis. — This  consists  of  the  exclusion  of  organic  disease. 

Prognosis. — The  cause  is  usually  detectable  by  an  intelligent 
and  properly  educated  physician,  and  its  removal  will  insure 
recovery. 

Treatment. — The  first  demand  is  for  temporary  relief  from  an 
attack.  Evacuation  of  the  bowels  with  enemata  and  the  application 
over  the  epigastrium  of  a  folded  handkerchief  moistened  with  chloro- 
form and  covered  with  a  towel  wrung  out  of  hot  water  will  usually 
afford  relief,  though  an  internal  administration  of  morphine  may 
sometimes  be  required.  Darting,  radiating  pains  sometimes  yield  to 
j)iper  methystictim  and  sometimes  to  colocynth,  dioscorea  or  bryonia. 
Copious  draughts  of  hot  water  sometimes  afford  relief.  A  lacerated 
uterus  should  be  repaired  and  rectal  pockets,  ulcers,  papillae,  hemor- 
rhoids and  spasmodic  stricture  should  be  properly  treated  when 
present  in  any  persistent  case.  Periodical  attacks  may  require  anti- 
periodic  doses  of  quinine  followed  by  the  prolonged  administration 
of  grindelia  squarrosa  in  appropriate  doses.  If  lead  poisoning  be 
suspected  the  proper  remedies  for  this  condition  should  be  pre- 
scribed. In  persistent  cases  a  radical  change  of  climate  may  suc- 
ceed in  relieving  when  other  treatment  fails. 

Many  cases  of  gastralgia  are  rheumatoid  in  character  and  occur 
in  persons  subject  to  muscular  rheumatism.  In  these  cases  we  will 
get  prompt  results  in  most  instances  from  generous  doses  of  cimici- 
fuga.  A  strong  decoction  of  the  recently  dried  root  in  wine-glassful 
doses  repeated  every  few  hours  will  usually  relieve  acute  cases 
within  a  short  time.  Smaller  doses  continued  for  a  few  days  at 
longer  intervals  will  usually  confirm  the  cure.  In  malarious  regions 
its  action,  however,  may  need  to  be  supplemented  by  that  of  a  prop- 
erly selected  antimalarial  agent.  In  other  cases,  especially  those 
which  have  reached  a  more  chronic  stage,  minute  doses  of  caulophyl- 
lin  may  be  more  efficacious  and  at  the  same  time  more  acceptable. 
Two  or  three  grains  of  the  2x  or  3x  trituration  of  a  good  article  of 
caulophyllin  should  then  be  administered  every  three  or  four  hours 
during  the  day  for  a  week  or  more.  Sometimes  rhamnus  californica 
will  serve  a  better  purpose  and  afford  more  prompt  relief.  A  table- 
spoonful  of  a  strong  decoction  of  the  bark  maybe  administered  every 
two  hours  until  a  laxative  effect  becomes  manifest,  after  which  the 
dose  should  be  lessened  or  the  remedy  discontinued  altogether. 


DISEASES  OF  THE  INTESTINES.  411 

NERVOUS  VOMITING. 

THIS  sometimes  occurs  when  there  is  no  organic  disease  to  cause 
it,  the  patient  being  unable  to  retain  food  of  the  simplest  character 
in  the  stomach.  It  is  usually  reflex  in  character,  the  vomiting  of 
pregnancy  and  sea-sickness  being  familiar  examples.  In  other  cases, 
however,  the  cause  may  be  more  obscure  and  the  condition  may  be 
so  persistent  as  to  threaten  inanition.  In  one  case  of  this  kind, 
where  the  patient  had  been  consigned  to  death  by  her  physicians 
under  the  diagnosis  of  cancer  of  the  stomach,  I  afforded  prompt  and 
permanent  relief  by  simply  stretching  the  sphincter  ani  with  the 
thumbs.  Doubtless  most  of  these  cases  may  be  referred  to  reflex 
rectal  irritation,  though  some  may  be  due  to  uterine  irritation  or 
other  reflexes.  In  managing  them  the  physician  should  examine  for 
all  possible  sources  of  reflex  disturbance,  and  when  a  probable  cause 
is  found  it  should  be  corrected  at  once.  If  this  fail  further  investi- 
tion  should  be  pursued. 

PERISTALTIC  UNREST. 

SOME  persons,  more  especially  women,  are  subject  to  loud  gur- 
gling or  splashing  sounds  in  the  epigastric  or  left  hypochondriac 
region,  due  to  peristaltic  unrest  of  the  stomach.  This  is  probably  a 
reflex  due  to  some  distant  disturbance  and  is  not  incompatible  with 
average  health.  General  tonic  faradic  treatment  with  local  faradiza- 
tion of  the  affected  region  is  beneficial,  though  permanent  relief 
is  not  always  accomplished. 

KUMINATION. 

HYSTERICAL  and  feeble-minded  persons  sometimes  regurgitate 
and  chew  the  food  like  cud-chewing  animals.  It  is  a  disgusting 
practice  and  difficult  to  cure,  though  there  is  little  danger  of  evil 
effects  from  it. 

VII.  DISEASES  OF  THE  INTESTINES. 

MORNING  DIARRHOEA. 

THIS  is  a  functional  affection,  the  etiology  and  pathology  of  which 
are  obscure.  It  consists  of  a  diarrhoea,  which  comes  on  during  the 
early  morning  hours,  sometimes  rousing  the  subject  from  slumber, 
the  evacuation  being  usually  preceded  by  more  or  less  severe  grip- 
ing pain  in  the  abdomen.  In  many  cases  one  evacuation  ends  the 
trouble  for  the  day,  though  several  may  follow,  the  diarrhoea  extend- 
ing well  into  the  forenoon. 


412  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

It  is  possibly  due  to  mental  disturbance,  such  as  worry  or  over- 
work, and  is  apt  to  be  aggravated  by  late  hours  with  evening  lunch- 
ing. Irritation  of  the  defecatory  center  may  arise  from  prolonged 
riding  over  rough  roads,  as  is  the  lot  of  many  country  doctors  who 
suffer  from  jar  of  the  spine.  Rectal  irritation  may  be  a  cause  through 
reflex  action.  Sometimes  the  trouble  may  cease  for  weeks  or  months, 
to  return  upon  deterioration  of  the  general  health. 

Treatment. — Late  hours  of  dissipation  should  be  carefully 
avoided  and  a  very  light  supper,  if  any,  should  be  taken,  and  this  not 
after  six  r.  M.  Mental  strain  should  be  prevented,  the  patient  taking 
exercise  on  foot  in  moderation  but  refraining  from  riding  or  any 
exercise  which  incurs  jarring  of  the  spine.  Careful  inspection  of 
the  rectum  should  be  made  to  detect  and  correct  any  local  lesions, 
if  any  exist.  Massage  of  the  abdomen  and  faradization  of  the  entire 
abdominal  surface  with  the  negative  pole  of  a  faradic  battery — the 
positive  pole  being  held  at  the  nape  of  the  neck — should  be  repeated 
twice  a  week.  Minute  doses  of  nux  vomica  (one  drop  of  the  tincture 
in  a  glass  of  water  before  each  meal)  may  be  tried  with  some  assur- 
ance of  benefit.  A  radical  change  of  climate  will  promote  the  best 
results. 

ACUTE  INTESTINAL  CATARRH. 

Synonyms. — Acute  Catarrhal  Enteritis;  Acute  Entero-colitis; 
Acute  Diarrhoea. 

Definition. — An  inflammation  of  the  intestinal  canal  involving 
the  small  intestine  and  in  many  cases  the  upper  portion  of  the  large 
bowel,  attended  by  catarrhal  symptoms  signalized  by  mucous  diar- 
rhoea with  griping  pains. 

Etiology. — The  causes  have  been  divided  into  primary  and 
secondary. 

Primary  causes  may  be  (1)  toxic  or  irritating  foods  or  drugs  of 
alkaline,  acid  or  corrosive  nature.  (2)  Errors  in  food  either  in 
quantity  or  quality,  some  articles  of  diet  proving  especially  detri- 
mental to  certain  individuals.  (3)  Impure  drinking-water  may  con- 
tain elements  which  give  rise  to  intestinal  irritation  and  inflamma- 
tion. (4)  Certain  changes  in  the  intestinal  secretions  are  believed 
to  result  in  enteritis.  (5)  Sudden  changes  in  temperature,  resulting 
in  congestion  of  the  mucous  membrane,  similar  to  that  which  causes 
"colds"  to  center  upon  the  pulmonary  mucous  membrane. 

Secondary  causes  are:  (1)  The  irritation  resulting  from  some  of 
the  infectious  diseases,  such  as  typhoid  fever.  (2)  Certain  cachetic 
conditions,  such  as  tuberculosis,  Bright's  disease,  cancer,  anaemia, 
etc.,  may  be  complicated  by  acute  attacks  of  enteritis.  (3)  Chronic 


DISEASES  OF  THE  INTESTINES.  413 

congestion  of  the  portal  circulation.      (4)  Peritonitis,  cancer  of  the 
intestines,  intestinal  ulcer,  hernia,  etc. 

Among  the  toxic  or  irritating  articles  of  food  may  be  mentioned 
the  toxines  developed  by  the  decomposition  of  cheese  and  milk. 
Arsenic,  mercury  arid  other  mineral  substances  act  in  a  similar  way. 
Unripe  fruit,  green  corn  and  other  such  materials  are  common 
causes  of  the  disease  during  the  heated  months  of  summer  and  early 
autumn.  Excessive  secretion  of  bile  is  supposed  to  be  one  of  the 
causes  of  this  disease,  and  mental  emotions  may  give  rise  to  such  a 
disturbance  of  the  intestinal  mucous  membrane  as  to  provoke  irri- 
tative diarrhoea. 

Pathology — The  branches  of  the  mesenteric  artery  distributed 
to  the  intestinal  mucous  membrane  are  injected  and  swollen,  the 
entire  mucous  membrane  is  reddened  and  engorged  and  the  surface 
is  covered  with  au  excessive  amount  of  mucus.  The  solitary  and 
agminated  glands  are  enlarged  and  stand  prominently  out  upon  the 
mucous  membrane  and  ulceration  of  the  follicles  and  mucous  surface 
may  occur.  After  death  the  reddened  mucous  membrane  becomes 
grayish,  sodden  and  flabby. 

Symptoms. — Colicky  pains  announce  the  advent  of  the  disease 
the  pains  preceding  the  evacuations  for  a  few  seconds,  the  call  to 
stool  being  urgent  and  the  evacuations  forceful  and,  if  the  lower 
bowel  is  involved,  marked  by  rectal  tenesmus.  More  or  less  tym- 
panites and  borborygmus  occur  during  the  attack,  these  usually  being 
most  marked  shortly  prior  to  evacuating.  There  are  loss  of  appe- 
tite, nausea,  thirst,  diyness  of  the  tongue  and  sense  of  debility  and 
prostration.  The  skin  is  dry  and  harsh  in  some  cases,  though  a 
relaxed  sweat  may  attend  the  demand  for  evacuation.  Slight  fever 
may  appear,  though  the  temperature  is  more  commonly  normal. 
The  evacuations  vary,  their  condition  depending  upon  the  period  of 
the  disease,  the  portion  of  the  intestine  most  involved  and  the  amount 
of  ingested  food  in  the  canal.  They  are  thin  and  gruel-like  in  con- 
sists.cy  and  vary  in  color  in  proportion  to  the  amount  of  bile  con- 
tained in  them.  They  may  contain  portions  of  undigested  food 
(lienteria)  and  much  mucus,  especially  when  the  colon  is  affected. 
From  five  to  twenty  evacuations  may  occur  in  a  day. 

Treatment. — The  recumbent  position  is  to  be  strictly  main- 
tained throughout  the  progress  of  the  disease,  as  frequent  rising  to 
stool  proves  a  continual  aggravation.  The  therapeutic  effect  of  the 
best  remedies  may  be  entirely  lost  if  the  patient  is  not  kept  down. 
A  bed-pan  is  to  be  used  and  the  patient  enjoined  to  make  as  little 
exertion  as  possible.  Aconite  and  ipecac,  in  combination,  is  the  ideal 
prescription  where  a  large  portion  of  the  intestine  is  involved.  The 
dose  should  be  small  and  frequently  repeated,  and  relief  of  perma- 


414  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

nent  character  will  follow  within  a  few  hours — at  least  within  a  day 
or  two.  The  following  combination  represents  the  proper  propor- 
tions: R  Lloyd's  or  Wordeu's  aconite  gtt.  v-x,  specific  or  normal 
tincture  ipecac  gtt.  x-xx,  water  fiv.  M.,  and  order  a  teaspoonful 
every  hour. 

Where  the  upper  portion  of  the  intestine  is  principally  involved, 
kali  bichrom.  2x  or  arsenicum  3x  may  be  more  efficacious.  Two  grains 
may  be  administered  every  two  hours.  The  2x  trituration  of  podo- 
phyllin  sometimes  acts  especially  well  here  also,  the  same  directions 
as  to  dose  and  frequency  of  administration  being  observed. 

Rhus  aromatica  acts  better  than  any  of  these  remedies  during 
some  attacks,  especially  where  provoked  by  hot  weather  and  ferment- 
ative processes.  From  two  to  ten  drops  of  the  specific  medicine  may 
be  administered  every  hour  and  repeated  until  benefit  follows,  then 
every  two  hours  until  complete  relief  is  obtained. 

Where  the  lower  intestine  is  the  part  principally  involved  mer- 
rius  cor.  6x  may  be  expected  to  yield  better  results  than  any  of  the 
remedies  already  named.  Five  or  ten  drops  of  the  dilution  or, two 
or  three  drops  of  the  trituration  may  be  administered  every  two 
hours  until  the  disease  is  controlled. 

Colocyntli  should  take  preference  of  all  other  remedies  where  pain 
is  the  prominent  symptom.  It  is  especially  indicated  where  there  is 
intense  griping  pain  about  the  umbilicus  accompanied  by  spas- 
modic cramps  of  the  abdominal  muscles  just  prior  to  the  evacuations. 
Half  a  teaspoonful  of  the  2x  or  3x  dilution  may  be  added  to  half  a 
tumblerful  of  water  and  a  teaspoonful  administered  every  half-hour 
or  hour  until  relief  follows.  It  may  be  necessary  to  follow  relief 
from  pain  with  one  of  the  remedies  already  named  to  complete  a 
cure,  though  this  will  not  always  be  necessary,  colocynth  frequently 
being  curative  as  well  as  palliative. 

Where  typhoid  symptoms  appear  and  the  patient  is  delirious, 
with  dry,  reddened  tongue,  nausea  and  vomiting,  rhus  tox.  should  be 
combined  with  the  properly  selected  remedy.  Where  the  discharges 
are  dark  and  offensive,  suggesting  putrid  conditions  of  the  intestinal 
mucous  membrane,  echinacea,  baptisia  or  sulpho-carbolate  of  sodium  may 
be  required.  The  sodium  salt  may  be  administered  in  quarter-grain 
doses  repeated  every  three  hours. 

Arseniate  of  copper  3x  is  strongly  indicated  where  the  evacuations 
are  watery  and  are  voided  with  a  forcible  gush.  One-grain  doses  of 
the  trituration  may  be  administered  at  one-  or  two-hour  intervals. 
Small  doses  of  the  3x  dilution  of  veratrum  album  answer  as  well  if 
not  better  in  some  cases,  and  sometimes  wineglassful  doses  of  a 
decoction  of  the  fresh  plant  erigeron  can.  repeated  every  half-hour  or 
hour  may  succeed  better. 


DISEASES  OF  THE  INTESTINES.  416 

Some  allopathic  practitioners  advise  the  administration  of  cathar- 
tic doses  of  castor  oil  or  calomel  in  the  beginning,  to  be  followed  by 
bismuth  and  astringents,  with  opiates  to  control  the  pain — a  very 
unsatisfactory  manner  of  management  in  most  cases  when  compared 
with  the  treatment  I  have  already  suggested.  When  there  is  great 
relaxation, and  the  discharges  persist  in  spite  of  the  treatment  advised 
and  an  astringent  seems  desirable,  a  decoction  of  erigeron  canadense 
may  be  employed  for  such  purpose,  as  it  does  not  irritate  the  intes- 
tinal mucous  membrane.  When  the  plant  cannot  be  obtained,  two- 
or  three-drop  doses  of  the  specific  medicine  diluted  in  water  may  be 
tried. 

The  general  management  of  enteritis  is  an  important  subject. 
The  patient  should  not  be  permitted  to  rise  to  stool,  however  urgent, 
ly  he  may  request  it,  as  every  time  the  erect  position  is  assumed  the 
intestinal  irritation  is  increased  and  the  frequency  of  the  evacuations 
encouraged.  Abed-pan  should  be  employed  to  receive  the  evacua- 
tions, and  the  patient  should  be  enjoined  to  avoid  defecation  as  long 
as  possible  in  order  to  encourage  rest  and  quiet  for  the  bowels. 

The  diet  should  consist  of  mutton  broth,  pancreatinized  milk  or 
milk  and  lime-water  (two  or  three  ounces  of  lime-water  to  the  pint 
of  miik).  After  the  disease  has  been  arrested  the  yolk  of  eggs  which 
have  been  boiled  an  hour  or  partially  cooked  (soft-boiled)  eggs,  raw 
oysters,  scraped  b  ef  with  toast  and  well  boiled  rice  may  be  given, 
care  being  observed,  if  the  case  has  been  a  severe  one  and  the  diar- 
rhoea has  continued  until  the  patient  has  become  prostrated,  to  return 
to  a  solid  diet  cautiously. 

Care  should  be  observed  to  prohibit  an  early  return  to  active 
habits  for  fear  of  provoking  a  relapse.  During  the  active  stage  of 
the  disease  the  patient  should  refrain  from  drinking  much  water,  as 
this  is  apt  to  increase  the  number  and  frequency  of  the  evacuations. 
Thirst  may  be  appeased  by  allowing  small  portions  of  ice  held  in  the 
mouth,  or  by  minute  doses  of  rhus  tox. 

In  malarious  districts  the  practitioner  should  be  on  the  alert  for 
malarial  complications,  properly  selected  remedies  often  failing  under 
such  circumstances  to  produce  their  specific  effects.  It  is  always  a 
safe  plan,  when  there  is  the  least  suspicion  of  malaria,  to  administer 
a  two-  or  three-grain  dose  of  arseniate  of  quinia  3x  three  times  daily, 
in  alternation  with  other  remedies. 

CHRONIC  INTESTINAL  CATARRH. 

Synonyms. — Chronic  Catarrhal  Enteritis;  Chronic  Diarrhosa; 
Chronic  Catarrhal  Entero-colitis. 

Etiology — Chronic  enteritis  is  due  in  the  majority  of  cases  to 


416  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

long-continued  use  of  improper  food  under  unhygienic  circumstances. 
Old  soldiers,  who  have  been  compelled  to  subsist  during  arduous 
campaigns  upon  hard-tack,  salt-pork,  underdone  beans  and  such  diet 
while  sleeping  on  the  ground  and  exposed  to  wet  and  cold,  are  the 
ones  most  subject  to  the  disease.  Repeated  acute  attacks  badly 
treated  may  be  followed  finally  by  chronic  diarrhoaa;  and  certain 
cachetic  conditions,  such  as  gout,  may  predispose  an  individual  to 
it.  It  often  arises  as  a  complication  of  chronic  disturbance  of  the 
portal  circulation,  such  as  that  arising  from  hepatic  cirrhosis  or 
splenic  hypertrophy.  Cancerous  or  tubercular  disease  of  the  intes- 
tines may  be  attended  by  it. 

Pathology. — The  small  intestine  and,  usually,  a  portion  of  the 
large  bowel  are  involved  in  the  morbid  change.  The  entire  wall  of 
the  intestine  is  frequently  thickened  by  hypertrophy  of  its  coats,  and 
the  mucous  membrane  is  reddened  and  congested  and  covered  with  a 
layer  of  tenacious  mucus.  The  glandular  elements  are  also  hype*> 
trophied  and  stand  out  in  relief,  ulceration  of  the  follicles  occasion- 
ally occurring.  Sometimes  atrophy  of  the  intestinal  canal  is  present 
instead  of  hypertrophy,  and  the  mucous  membrane  is  leaden-gray  in 
color  and  the  glandular  elements  shrunken.  The  villi  may  be  pig- 
mented  in  patches,  imparting  a  "shaven  beard"  appearance  to  the 
mucous  membrane.  Where  ulceration  of  the  follicles  is  general  the 
intestine  may  be  perforated  with  a  honey-comb  suppurating  surface, 
and  perforation  or  hemorrhage  may  be  the  result.  Adhesions  of  the 
peritoneal  surfaces  of  the  intestines  may  occur  and  serous  exudation 
may  give  rise  to  ascitic  accumulation  in  the  peritoneal  sac. 

Symptoms. — The  symptoms  resemble  those  of  acute  enteritis, 
though  there  may  be  periods  of  constipation,  during  which  there  is 
more  than  usually  severe  distress.  Attacks  of  diarrhoea  follow  indis- 
cretions in  diet  in  mild  cases  ana  food  of  any  kind  provokes  distress, 
gastric  and  intestinal,  when  the  condition  is  aggravated.  The  stools 
are  thin  and  gruel-like,  containing  mucus  and  debris  of  undigested 
food,  with  streaks  of  blood  and  pus  whenever  there  is  extensive 
ulceration.  The  evacuations  are  preceded  and  accompanied  by 
severe  griping  pain  in  the  abdomen,  and  painful  tenesmus  attends 
when  the  irritation  extends  low  in  the  bowel,  it  nearly  always  ap- 
pearing two  or  three  hours  after  eating.  There  may  be  from  one  to 
eight  evacuations  during  the  day,  and  during  aggravations,  which 
may  arise  from  cold  or  dietary  indiscretion,  there  may  be  a  much 
larger  number.  Flatulence  and  borborygmus  are  common  to  such 
cases  and  hypochondriasis  and  melancholia  are  frequently  present. 
Gradual  failing  of  health  and  strength  result  and  during  advanced 
stages  the  patient  may  become  extremely  emaciated  and  prostrated. 
Ascites  may  then  arise,  especially  where  there  is  hepatic  complica- 


DISEASES  OF  THE  INTESTINES.  417 

lion;  and  later  anasarca  may  occur.  The  skin  becomes  sallow  and 
pallid,  the  pulse  feeble  and  rapid,  and  the  patient  may  finally  die 
with  typhoid  symptoms. 

Prognosis. — There  is  little  hope  in  aggravated  cases,  though 
recovery  may  follow  treatment  begun  at  an  early  period.  Perforation 
of  the  bowel  is  an  occasional  accident. 

Treatment. — Attention  to  diet  is  one  of  the  most  important 
matters  to  be  considered  in  treatment.  Food  should  be  liquid  in 
form,  and  skimmed  milk  is  probably  most  appropriate  when  diluted 
with  lime-water.  Sometimes  the  milk  is  more  acceptable  when  boiled. 
An  excellent  plan  is  to  put  the  patient  upon  an  exclusive  milk  diet 
for  several  weeks  until  curative  treatment  is  under  way.  Beef  pep- 
tonoids,  scraped  raw  beef,  beef  meal  and  similar  articles  are  useful. 
Fatty  and  saccharine  kinds  of  food  should  be  avoided  and  only  a 
small  amount  of  farinaceous  food  should  be  allowed.  In  the  treat- 
ment of  such  cases  the  practitioner  should  consult  standard  authori- 
ties on  dietetics  for  a  variety  of  foods.  Fats,  sugar,  very  rich  milk, 
green  vegetables,  acid  fruits  and  dried  fruits,  nuts,  shell-fish,  pork, 
veal,  coarse  bread,  pastries,  cakes  and  desserts  of  every  description 
should  be  discarded. 

This  is  an  excellent  place  for  the  administration  of  the  dry  diet. 
From  some  limited  experience  I  am  convinced  that  severe  cases  may 
be  thus  controlled,  provided  they  be  not  too  far  advanced.  If  the 
patient  can  be  induced  to  persevere  in  this  for  a  few  weeks  little 
medicine  may  be  needed  to  perfect  a  cure.  The  great  difficulty  is  to 
imbue  the  subject  with  enough  faith  to  hold  out  to  the  end.  The 
diet  should  consist  of  stale  bread,  thoroughly  masticated,  with  two 
ounces  of  plain  claret  four  or  five  times  a  day,  and  nothing  else.  All 
fluids  should  be  sedulously  avoided  as  well  as  solids. 

To  remove  accumulations  of  tenacious  mucus,  liydrozone  may  be 
of  service,  a  drachm  being  diluted  with  four  ounces  of  distilled  or 
boiled  water,  two  ounces  of  the  amount  being  taken  before  break- 
fast for  two  or  three  consecutive  mornings,  the  agent  to  be  repeated 
as  circumstances  seem  to  demand.  Glycozone  may  sometimes  be  sub- 
stituted with  advantage. 

To  encourage  reparation  of  the  diseased  mucous  membrane,  ber- 
beris  aquifolium  is  an  excellent  remedy,  especially  if  there  be  ulcera- 
tion  to  contend  with.  Epilobium  continued  for  a  long  time  often 
affords  satisfactory  results  in  cases  not  too  far  advanced.  Kalci  is 
another  remedy  of  especial  service  for  this  purpose,  especially  when 
a  recent  preparation  can  be  obtained.  Rims  aromatica  is  also  an 
excellent  remedy,  especially  to  relieve  acute  aggravations.  Mercu- 
rius  dulcis  or  corrosivus  6x  may  be  relied  upon  to  alleviate  irrita- 
tion of  the  colon  and  heal  abraded  surfaces  there.  Severe  colicky 

28 


418  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

pains  may  call  for  cdocynth,  especially  when  the  neurosis  is  about 
the  umbilicus,  and  collinsonia  if  the  rectal  or  hypochondriac  region 
is  the  seat  of  pain.  Reference  to  Dynamical  Therapeutics  will  afford 
more  information  as  to  details  in  the  use  of  these  remedies. 

The  tissue  remedies  sometimes  exert  an  excellent  influence  in 
these  cases.  Where  there  is  emaciation  and  anaemia  calcium  phos. 
3x  may  prove  an  excellent  remedy.  Calcium  sulphate  3x  may  be 
applicable  to  cases  where  there  is  profuse  purulency,  and  natrum 
chlor.  3x  where  there  is  much  watery  discharge. 

Massage  over  the  abdominal  region,  where  there  is  not  too  much 
tenderness,  and  general  massage,  as  well  as  local  and  general  faradi- 
zation, are  useful  to  assist  in  a  cure.  The  skin  should  be  protected 
with  flannel  and  sudden  changes  should  be  avoided.  A  winter  resi- 
dence in  a  warm  climate  is  always  appropriate. 

PHLEGMONOUS  ENTERITIS. 

THIS  is  a  very  grave  disease  and  one  that  usually  terminates 
fatally.  The  abdomen  is  distended,  tympanitic  and  very  tender 
to  touch,  there  are  pain  and  tormina  in  an  intense  degree,  the  patient 
breaking  out  into  profuse  perspiration,  with  frequent  and  violent 
vomiting,  the  ejected  material  becoming  fecal  in  most  cases  late  in 
the  disease.  The  pulse  is  small,  rapid  and  compressible  and  the 
temperature  elevated  (103°  to  105°  F.).  There  is  marked  and  rap- 
idly progressive  prostration  in  fatal  cases,  the  countenance  becoming 
shriveled  and  the  extremities  cold,  hiccough  and  jactitation  coming 
on  later,  and  finally  collapse  and  death.  In  favorable  cases  diarrhoea 
sets  in,  the  tongue  becoming  dry,  red  and  glazed  and  the  patient 
greatly  prostrated  for  a  time,  the  symptoms  afterward  gradually 
ameliorating  and  slow  recovery  following. 

Treatment. — Potassium  chloride  3x,  echinacea  and  baptisia  are 
the  most  rational  remedies.  Solid  food  should  be  avoided  and  the 
patient  should  maintain  the  horizontal  position  until  convalescence. 

PSEUDO-MEMBRANOUS  ENTERITIS. 

Synonyms.— Diphtheritic  Enteritis;  Croupous  Enteritis. 

Definition. — An  intense  inflammation  of  the  intestine,  charac- 
terized by  an  exudate  and  destructive  processes  involving  the  mucous 
and  submucous  structures. 

Etiology. — Many  causes  may  result  in  this  form  of  intestinal 
inflammation.  It  is  not  an  unfrequent  attendant  of  the  infectious 
fevers,  especially  of  typhoid  fever,  scarlatina,  pyaemia,  etc.  It  may 
attend  the  last  stages  of  such  chronic  affections  as  cirrhosis  of  the 


DISEASES  OF  THE  INTESTINES.  419 

liver,  cancer,  Bright's  disease  and  other  cachetic  conditions,  and  may 
be  present  in  poisoning  from  various  mineral  agents,  such  as  mer- 
cury, arsenic  and  lead. 

Pathology. — The  exudate  is  thrown  out  upon  the  mucous  sur- 
face, involving  it  in  in  a  state  of  coagulation  necrosis.  Sometimes  it 
is  extensive  and  crust-like  and  at  other  times  it  may  constitute  a 
thin  film,  the  mucous  membrane  being  necrotic  in  both  instances. 
In  other  cases  the  exudation  appears  in  small  amount  about  the 
openings  of  the  solitary  follicles,  small  ulcers  corresponding  to 
these  openings  being  scattered  about  over  the  mucous  surface. 
Sometimes  the  follicles  are  capped  with  a  raised  diphtheritic  mem- 
brane. 

Symptoms. — The  symptoms  vary  greatly  in  character  and 
severity.  Sometimes,  as  when  the  exudation  occurs  in  the  termi- 
nal stages  of  infectious  fevers  and  other  constitutional  conditions, 
there  may  not  be  much  inconvenience  from  it,  while  in  toxic 
cases  intense  pain,  with  diarrhoea,  may  attend.  Sometimes  the 
presence  of  the  disease  will  not  be  suspected  until  accidentally 
observed  during  autopsy.  Shreds  of  membrane  may  be  voided  in 
the  faeces. 

Treatment. — Echinacea  and  lachesis  fortify  the  system  against 
necrosis,  and  potassium  chloride  against  plastic  exudation.  Colocynth 
alleviates  intestinal  pain  and  tenesmus.  A  liquid  diet  provides 
against  danger  of  perforation  and  destructive  mechanical  action,  and 
rest  in  the  recumbent  posture  favors  restoration  by  providing 
against  undue  peristalsis. 

Mucous  COLITIS. 

Synonyms. — Membranous  Enteritis;  Tubular  Diarrhoea;  Mu- 
cous Colic. 

Definition. — A  chronic  disease  of  the  colon  of  mild  character, 
characterized  by  the  formation  of  masses  of  tenacious  mucus,  which 
may  be  voided  in  long,  stringy,  irregular  masses  or  in  the  form  of 
tubular  membranes. 

Etiology. — Some  derangement  of  the  mucous  glands  of  the 
colon  is  the  cause  of  the  peculiar  secretion.  What  the  exact  patho- 
logical condition  is  remains  a  question,  rectal  pockets  and  papillae 
often  being  attended  by  it.  It  is  most  common  in  women  of  nerv- 
ous, excitable  temperament,  hysterical  women  or  neurasthenic  men 
being  favorable  subjects,  though  it  may  occur  occasionally  in 
children. 

Pathology, — There  are  few  if  any  pathological  changes  to  be 
bserved,  though  the  lower  inch  of  the  rectal  mucosa  may  be  con- 


420  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

gested.  The  masses  of  mucus  may  often  be  seen  through  the  spec- 
ulum, sometimes  deposited  in  irregular  layers,  sometimes  in  flakes 
and  sometimes  in  tubular  form. 

Symptoms. — Paroxysms,  characterized  by  abdominal  pain  and 
rectal  tenesmus,  come  on  at  intervals  of  a  month  or  more,  sometimes 
lasting  for  several  days,  during  which  the  mucus  is  voided.  The 
subjects  are  usually  hysterical  or  neurasthenic  and  they  are  fre- 
quently hypochondriacal.  There  is  no  fever. 

Prognosis. — The  disease  runs  a  chronic  course  and  may  con- 
tinue for  years  without  serious  results  to  the  general  health,  though 
the  patient  may  be  in  a  condition  of  semi-invalidism  through  the 
attending  neurasthenia..  Much  benefit,  and  often  a  cure,  may  result 
from  rational  treatment. 

Treatment. — As  rectal  irritation  is  liable  to  be  the  chief  pro- 
voking cause,  careful  search  must  be  made  for  concealed  rectal  pock- 
ets, papillae  and  ulcers.  When  such  pathological  conditions  are 
found  they  must  be  radically  treated,  the  pockets  and  papillae  being 
excised  and  the  ulcers  healed.  This  treatment  should  be  followed 
by  daily  copious  flushing  of  the  lower  bowel  with  a  saturated  solu- 
tion of  sodium  chloride  in  water,  the  water  to  be  lukewarm,  espe- 
cially in  female  subjects,  the  daily  flushing  being  continued  for  a 
year.  Electrolysis  of  the  lower  bowel  through  the  salt-water  injec- 
tion is  an  excellent  curative  measure.  It  should  be  applied  twice 
weekly.  Internally,  the  following  prescription  may  be  used  steadily 
for  months:  R  Specific  sambucus  canadensis  31!,  specific  phytolacca 
^i,  fluid  extract  berberis  aquifolium  f i,  fluid  extract  grindelia  squar- 
rosa  f  i,  aqua  ad  •$  vi.  8.  Take  a  teaspoonful  before  each  meal  and  at 
bedtime — four  times  daily. 

ULCEBATIVE  ENTERITIS. 

ULCERATTON  of  the  intestines  may  arise  from  numerous  causes. 
Sometimes  the  symptoms  are  prominent  and  sometimes  hardly 
detectable,  the  disease  running  a  latent  course  and  the  condition  fin- 
ally being  accidentally  observed  during  autopsy,  this  being  the  first 
revelation  of  the  existence  of  a  lesion.  The  following  kinds  of 
intestinal  ulceration  have  been  noted: 

Peptic  or  round  ulcer  of  the  duodenum  occurs  in  about  one  in 
forty  of  the  cases  observed,  the  majority  affecting  the  stomach.  There 
is  less  vomiting  here  than  in  peptic  ulcer  of  the  stomach,  and  the 
pain  which  follows  eating  comes  on  later  than  in  the  gastric  variety 
and  is  not  so  severe.  There  is  tenderness  over  the  right  hypochon- 
drium  and  in  about  one-third  of  the  cases  hemorrhage  ensues.  lu 
other  cases  there  is  little  pain  or  discomfort  and  the  disease  runs  a 


DISEASES  OF  THE  INTESTINES.  421 

latent  course,  sudden  death  following  perforation  of  the  intestine, 
the  cause  of  demise  being  determined  by  autopsy  only.  Stenosis  of 
the  pylorus  with  gastrectasis  may  occur,  or  peritonitis  with  or  with- 
out peritoneal  abscess.  Sometimes  there  is  obstruction  of  the  com- 
mon bile  duct  or  pancreatic  duct.  Perforation  is  usually  announced 
by  several  days'  severe  continuous  pain  in  the  right  hypochondrium. 
The  prognosis  is  more  serious  than  that  of  gastric  peptic  ulcer.  The 
treatment  should  be  followed  on  similar  lines. 

Duodenal  ulceration  may  follow  extensive  burns  of  the  skin.  This 
depends  upon  some  peculiar  sympathy  which  is  not  well  understood. 
The  intestinal  complication  comes  on  in  one  or  two  weeks  after  the 
burn  in  the  form  of  irregular  patches  of  congestion  and  ulceration  of 
the  duodenal  mucous  membrane,  the  ulceration  proceeding  to  de- 
structive action  upon  the  intestinal  walls,  attended  by  hemorrhage 
and  perforation  with  fatal  result.  The  prognosis  is  unfavorable 
almost  invariably. 

Embolic  ulcers  of  the  small  intestine  may  arise  from  obstruction 
of  a  branch  of  the  superior  mesenteric  artery,  the  colon  almost  always 
escaping  this  form  of  ulceration.  Small  necrotic  areas  appear  upon 
the  intestinal  wall  at  points  corresponding  to  the  terminations  of  the 
obstructed  vessels,  infarction  of  the  mucous  membrane  and  deeper 
structures  producing  them.  Extensive  suppuratior.  of  the  intestinal 
wall,  followed  by  peritonitis  and  perforation,  may  follow.  Intense 
pain,  with  profuse,  foetid  discharges,  typhoid  symptoms  of  rapid  rise, 
collapse  and  death  are  the  usual  symptoms. 

Amyloid  degeneration  of  the  terminal  arteries  of  the  mesentery 
may  be  followed  by  ulcers,  which  progress  steadily  to  a  fatal  termi- 
nation. Permanent  obstruction  of  the  arterial  supply  renders  resto- 
ration impossible. 

Catarrhal  &ndfollicular  ulcers  may  occur  in  the  alimentary  canal, 
either  in  acute  or  chronic  form.  Catarrhal  ulcers  are  superficial  ero- 
sions of  the  mucous  membrane  of  the  colon,  sometimes  spreading 
widely,  resulting,  in  chronic  cases,  in  induration  of  the  intestinal 
wall  and  tending,  on  recovery,  to  cicatrization  and  narrowing  of  the 
passage.  Follicular  ulcers  may  occur  in  either  the  large  or  small 
bowel.  They  consist  of  single  ulcers  with  excavated  edges,  but  may 
extend  so  as  to  communicate  with  one  another  or  perforate  the 
bowel.  When  extensive,  they  are  seldom  repaired. 

Stercoral  ulcers  are  the  result  of  abrasions  caused  by  irritating 
fecal  material.  They  are  usually  found  where  hardened  fecal  mater- 
ial is  liable  to  be  retained  for  a  long  time,  as  above  intestinal  stric- 
tures, in  the  caecum,  flexures  of  the  colon,  sigmoid  flexure  or  in  the 
rectum.  Destruction  of  the  mucous  surface  with  purulent  infiltra- 
tration  occurs  at  points  of  continued  pressure. 


422  DISEASES  OP  THE  DIGESTIVE  ORGANS. 

Tubercular  ulceration  of  the  intestine  is  of  common  occurrence 
in  tubercular  subjects,  secondary  infection  resulting  in  pulmonary  or 
genito-urinary  tuberculosis.  In  other  cases  direct  infection  may 
arise  from  the  ingestion  of  food  contaminated  with  tubercle  bacilli, 
as  in  the  instance  of  infected  milk.  Tubercles  first  develop  in  the 
solitary  or  agminated  glands  of  the  ileum  and  spread  from  there  up- 
ward and  downward,  involving  the  entire  intestinal  canal.  The  mes- 
enteric  vessels  become  involved  and  the  intestine  becomes  girdled 
with  tubercular  deposits,  which  form  along  the  course  of  these  chan- 
nels and  break  down,  leaving  ulcerated  surfaces  encircling  the  intes- 
tine at  right  angles  with  the  longitude  of  its  lumen.  The  peritoneal 
surface  of  the  intestine  becomes  studded  with  tubercles  and  the 
inflammatory  exudation  furnishes  adhesive  material  to  weld  the 
opposing  peritoneal  surfaces  together.  Tubercular  deposits  spread 
to  the  mesenteric  glands  and  these  become  enlarged  and  nodular. 
The  "girdle"  character  of  the  ulcers  serves  to  distinguish  them  from 
other  forms.  Perforation  of  the  bowel  sometimes  occurs,  and  heal- 
ing by  cicatrization  has  been  possible. 

Syphilitic  ulcers  occur,  in  the  adult,  almost  exclusively  in  the  rec- 
tum, where  they  cause  progressive  fibrous  stricture.  They  are  most 
frequently  found  in  women.  Syphilitic  ulceration  of  the  small 
intestine  may  occur  in  congenital  syphilis.  Gummata  sometimes 
form  in  the  intestinal  wall,  their  dissolution  being  followed  by  obsti- 
nate ulcers. 

[frcemic  ulcers  occur  in  connection  with  advanced  nephritis,  some- 
times of  gangrenous  character,  sometimes  follicular  and  again  as  a 
result  of  pseudo-membranous  enteritis. 

Mercurial  ulcers  follow  poisoning  by  mercury  and  are  left  after 
the  pseudo-membranous  enteritis,  which  then  arises. 

The  ulceration  which  attends  typhoid  fever,  diphtheria,  anthrax 
and  other  infectious  diseases  has  already  been  referred  to. 

Peritoneal  erosion  from  the  pressure  of  abdominal  tumors  may 
result  in  intestinal  ulcers,  and  a  neighboring  abscess  may  perforate 
the  intestine  from  its  external  surface  and  cause  ulceration. 

Cancerous  ulceration  of  the  intestine  will  be  referred  to  later. 

The  symptoms  of  intestinal  ulceration  vary  greatly,  the  location 
and  character  of  the  condition  determining  its  nature  and  gravity. 
Limited  ulceration  of  any  part  of  the  intestine  may  be  attended  by 
constipation,  but  diarrhoea  is  a  common  symptom  when  ulceratiou  is 
extensive.  Hemorrhage  is  a  common  symptom,  though  its  amount 
will  depend  upon  the  depth  of  the  ulcerative  action.  Typhoid  ulcers 
and  those  occurring  in  the  duodenum  are  attended  by  the  greatest 
amount  of  hemorrhage,  though  perforations  of  the  intestine  from 
without  are  liable  to  be  followed  by  extensive  hemorrhage.  Pus  is 


DISEASES  OF  THE  INTESTINES.  423 

always  present  and  its  presence  is  diagnostic.  Sometimes  it  is  so 
limited  in  quantity  as  to  require  microscopical  inspection  of  the 
faeces  to  detect  it,  and  at  other  times  it  may  be  present  in  large  quan- 
tity, casual  inspection  affording  evidence  of  it.  Profuse  evacuations 
of  pus  indicate  the  discharge  of  an  abscess  into  the  intestinal  canal. 
Pus  mixed  with  blood  and  mucus  indicates  the  presence  of  an  irri- 
table ulcer  near  the  lower  outlet,  such  as  that  of  cancer  of  the 
sigmoid  flexure  or  rectum.  In  tubercular  ulceratiou  tubercle  bacilli 
are  liable  to  be  found  in  the  evacuations,  and  shreds  of  mucous 
membrane  suggest  rapid  and  extensive  ulceration,  though  care 
must  be  exercised  that  portions  of  undigested  food  be  not  mistaken 
for  them. 

Pain  may  or  may  not  be  present.  Sometimes  intestinal  ulcers 
run  a  latent  course  and  the  patient  does  not  experience  any  pain 
throughout.  Sometimes  colicky  pains  of  spasmodic  character  may 
attend  and  are  aggravated  by  taking  food.  Sometimes  the  pain  is 
forceful  and  tenesmic  in  character,  suggesting  irritation  in  the 
colon  or  rectum,  and  is  aggravated  by  motion  of  the  bowels. 
Sometimes  the  pain  is  constant,  suggesting  peritoneal  tenderness. 
Tenderness  may  or  may  not  be  present.  When  a  small  area  is  sen- 
sitive to  pressure  the  symptom  is  valuable  as  localizing  the  seat  of 
ulceration. 

Fever  and  emaciation  may  be  present,  depending  upon  the  extent 
and  character  of  the  ulceration.  Intestinal  obstruction  from  cicatri- 
zation, localized  peritonitis,  peritoneal  abscess  and  perforative  peri- 
tonitis are  among  the  complications  of  intestinal  ulceration. 

Treatment. — A  properly  selected  diet  stands  first  among  con- 
siderations of  treatment.  A  milk  diet  is  best  in  most  cases,  though 
provision  should  be  made  against  the  formation  of  hard  curds  by  the 
addition  of  lime-water.  As  the  upright  position  encourages  peri- 
stalsis and  thus  tends  to  aggravate  intestinal  disease,  rest  in  bed  is 
the  best  course  to  pursue  during  treatment.  The  yolks  of  eggs 
boiled  for  an  hour  and  taken  with  a  little  salt  may  be  alternated 
with  the  milk  diet  when  this  becomes  too  irksome,  and  after  im- 
provement begins  soft-boiled  eggs,  raw  oysters,  minced  beef  and 
chicken,  soda  crackers,  bread  and  milk,  toast,  blanc-mange,  custard, 
junket  and  wine-jelly  may  be  allowed.  Acids,  pickles,  raw  fruits  and 
all  indigestible  foods  should  be  prohibited,  and  meals  should  be 
limited  as  to  quantity,  the  patient  being  fed  often  and  a  little  at  a 
time — five  or  six  times  a  day. 

When  the  ulceration  is  in  the  upper  portion  of  the  alimentary 
canal,  two  ounces  of  diluted  Jiydrozonc — one  or  two  parts  to  thirty- 
two  of  distilled  or  sterilized  water — should  be  given  two  or  three 
times  daily  to  destroy  pus  microbes,  disinfect  the  alimentary  canal 


424 


DISEASES  OF  THE  DIGESTIVE  ORGANS. 


and  stimulate  reparative  action  in  the  ulcers.  When  the  lower  bowel 
is  affected,  high  injections  of  the  same  agent  may  prove  serviceable. 
The  constitutional  influence  of  berberis  aquifollum  in  ulceration  of  the 
soft  tissues  should  be  made  avail  of,  and  if  the  ulceration  should  be 
syphilitic  it  may  be  advantageously  combined  with  corydalisjormofsa. 
When  the  small  intestines  are  ulcerated,  kaki  may  be  of  service,  and 
also  epilobium.  Salicylate  and  subnitrate  of  bismuth  are  to  be  remem- 
bered. Tubercular  ulceration  should  be  treated  with  bovinlne,  such 
auxiliary  treatment  as  special  cases  demand  being  added.  Ulcera- 
tion of  the  colon  and  rectum  may  demand  the  use  of  the  salt-water 
electrode  with  galvanism  applied  every  second  or  third  day  for 
months.  Colicky  pains  may  demand  colocynth,  dioscorea  or  stannum  3x. 
In  follicular  ulceration  of  the  small  intestine  kali  bichrom.  3x  may 
be  of  service,  and  mercurius  cor.  6x  exerts  a  similar  influence  upon 
the  colon.  The  pain  of  cancerous  ulceration  demands  echinacea. 

The  galvanic  rectal  douche  is  a  simple  arrangement  for  conveying 
electricity  directly  to  the  interior  of  the  bowel.  In  ulceration  of 
this  part,  and  in  pns  pockets  communicating  with  the  lower  bowel, 
it  is  a  superior  means  of  treatment.  However,  it  is  efficacious  in 
confirmed  torpidity  of  the  lower  bowel,  proving  curative  in  long- 


standing constipation  as  well  as  in   chronic  catarrhal  conditions  of 
the  rectum  and  colon. 

In  addition  to  an  ordinary  galvanic  battery  with  the  usual  sponge 
electrode,  the  apparatus  consists  of  two  yards   of  half-inch  rubber 


DISEASES  OF  THE  INTESTINES.  425 

hose,  three  yards  of  copper  wire  (the  size  of  an  ordinary  knitting 
needle)  and  a  small  glass,  rubber  or  tin  funnel  (glass  or  hard  rub- 
ber being  preferable  to  the  metal  on  account  of  non-conducting 
properties). 

In  using  the  patient  is  instructed  to  lie,  either  on  a  cot  or  on  a 
rug  on  the  floor,  in  the  Sims  position,  the  floor  being  better.  One 
end  of  the  rubber  hose  is  oiled  and  inserted  into  the  rectum  an  inch 
or  two  and  the  funnel  is  adjusted  to  the  other  end  to  facilitate  the 
introduction  of  the  water  when  all  is  ready.  The  copper  wire  is  now 
passed  through  the  funnel  and  into  the  tube  and  carried  along  until 
the  lower  end  reaches  the  lower  extremity  of  the  tube,  though  it 
should  not  protrude  from  it,  as  a  painful  effect  may  result  from  the 
current  when  the  metal  is  in  contact  with  the  mucous  membrane  of 
the  bowel.  The  upper  end  of  the  wire,  which  should  be  a  yard  or 
more  longer  than  the  tube,  should  be  attached  to  one  pole  of  the 
battery  to  be  used,  the  selection  to  be  made  according  to  the  condi- 
tion to  be  treated.  A  conducting  cord  should  now  be  fastened  to  a 
moistened  sponge  electrode  and  attached  to  the  opposite  pole,  when 
all  is  ready  for  operation.  After  the  tube  has  been  introduced  a 
strong  solution  of  warm  salt  water  should  be  poured  into  the  ele- 
vated funnel,  the  patient  meanwhile  holding  the  sponge  upon  the 
naked  abdomen  and  stroking  it  backward  and  forward  over  the  entire 
abdominal  surface.  As  long  as  the  water  flows  into  the  tube  freely 
it  should  be  gradually  added,  a  gallon  sometimes  being  received 
without  much  discomfort.  The  current  may  be  ten  or  twelve  inilli- 
amperes  in  strength — all  that  a  common  portable  32-cell  Mclntosh 
battery  can  generate,  and  the  seance  can  be  continued  for  twenty 
minutes  or  half  an  hour.  Powerful  tenesmus  may  attend,  but  the 
patient  should  be  instructed  to  resist  this  and  retain  the  fluid  as  long 
as  possible  in  order  to  derive  the  full  benefit  of  the  treatment.  Its 
value  in  many  morbid  states  of  the  lower  bowel  and  pelvis  is  not 
half  appreciated. 

DYSENTERY. 

Synoii3*ms — Bloody  Flux;  Recto-Colitis. 

Treatment. — A  specific  and  non-specific  inflammation  of  the 
large  intestine,  attended  by  fever,  tormina  and  tenesmus,  and  charac- 
terized by  frequent  evacuations  of  tenacious  mucus  mixed  with  more 
or  less  blood. 

Etiologj". — Dysentery  is  divided  into  non-specific  or  that  form 
for  which  a  specific  cause  has  not  been  determined,  and  specific, 
tropical  or  amoebic  dysentery,  due  to  the  presence  of  the  amcelta 
coli  in  the  bowel.  The  drinking  of  stagnant  water  is  believed  to 


426  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

originate  the  disease,  and  epidemics  arising  during  the  late  summer 
and  early  autumn,  when  the  dry  season  is  prevailing,  may  be  due  to 
low,  stagnant  water  from  which  the  drinking  supplies  are  obtained. 
This  is  especially  liable  to  be  the  case,  the  dysentery  being  of  severe 
form,  when  many  are  congregated  together,  as  in  military  camps,  the 
disease  probably  being  spread  by  contamination  of  the  drinking 
water  from  neighboring  cesspools.  Doubtless  the  same  causes  pre- 
vail in  a  more  restricted  degree  in  rural  districts,  where  sanitary 
provisions  do  not  insure  immunity  from  contamination  of  this  kind. 
Dr.  W.  C.  Cooper  (Eclectic  Medical  Gleaner)  has  recently  reported 
that  the  precaution  of  boiling  the  drinking  water  in  an  epidemic  of 
the  disease  where  he  practiced  (in  1896)  did  not  prevent  it  from 
spreading  to  those  who  confined  themselves  to  the  use  of  that  water 
after  the  epidemic  began;  but  it  is  to  be  recollected  that  the  founda- 
tion may  have  been  laid  for  weeks  before  the  disease  manifested 
itself — that  those  who  suffered  from  attacks  might  have  all  been  con- 
taminated before  the  first  case  became  known.  The  germs  of  the 
disease  seem  to  sometimes  exist  in  fruits  and  vegetables,  especially 
unripe  fruits,  or  there  must  be  a  variety  which  may  arise  from  fer- 
mentation and  local  irritation,  outside  of  any  specific  microbic  cause, 
from  eating  unripe  fruits  and  such  vegetables  as  cucumbers,  as 
attacks  often  follow  so  soon  upon  the  eating  of  such  articles  as  to 
render  it  obvious  that  their  use  has  direct  connection  with  the  mal- 
ady. After  an  attack  of  dysentery  one  is  apt  to  suffer  regularly  at 
the  same  season  year  after  year,  unless  successfully  treated  early  for 
one  or  two  seasons.  Sudden  arrest  of  the  cutaneous  secretion  may 
precipitate  an  attack  of  dysentery,  especially  during  the  heated  term. 
Antihygienic  surroundings  other  than  those  already  mentioned,  such 
as  foul  air,  depressing  agencies,  malarial  influences  and  acute  febrile 
attacks,  seem  to  predispose  to  it. 

Pathology. — In  follicular  dysentery  the  membrane  of  the  lower 
colon  and  rectum  becomes  congested,  swollen  and  reddened,  the  red- 
ness varying  in  intensity  in  different  portions  of  its  surface  from  a 
bright-red  color  to  a  dusky  or  purplish  hue;  the  entire  surface  is  cov- 
ered with  tenacious  mucus,  and  the  follicles  are  enlarged  from  serous 
infiltration  and  proliferation  of  the  new  epithelial  elements.  As  the 
inflammation  progresses  destructive  action  follows,  and  necrosis  may 
begin  in  the  follicles  and  small  ulcers  form.  As  these  spread  several 
may  coalesce  to  form  irregular  ragged  ulcers,  and  in  severe  cases 
these  may  undermine  the  mucous  membrane  and  penetrate  the  sub- 
mucous  and  muscular  coats.  Complete  perforation  of  the  peritotfeal 
coat  occurs  in  rare  instances.  In  epidemics  of  typhoid  dysentery 
there  is  apt  to  be  marked  necrotic  tendency  about  the  affected  tis- 
sues, and  the  destructive  action  is  much  more  extensive  than  in  spo- 


DISEASES  OF  THE  INTESTINES.  427 

radio  cases.  The  pathological  changes  in  amoebic  dysenterv  are  also 
liable  to  be  of  serious  character. 

Diphtheritic  dysentery  sometimes  occurs,  when  the  ulcers  arise 
independently  from  the  follicles  and  are  more  extensive  and  destruc- 
tive. The  ulcers  are  covered  with  a  yellowish,  fibrinous  exudation, 
the  longitudinal  axis  corresponding  to  the  fold  of  mucous  membrane 
between  the  pouches,  and  the  first  layer  is  penetrated  and  the  sub- 
mucous  coat  infiltrated  with  pus.  Serious  undermining  of  the  mem- 
brane is  apt  to  occur  in  this  form,  it  being  more  destructive  than  fol- 
licular  dyesentery.  Sometimes  tubular  casts  of  a  considerable  por- 
tion of  the  colon  may  be  formed  by  the  pseudo-membrane. 

In  amoebic  dysentery  the  amoebi  are  found  in  the  bottoms  of  the 
ulcers  and  in  the  neighboring  bloodvessels  and  lymph-channels. 
Purulency  is  not  marked  in  this  form,  and  destructive  local  action  is 
not  so  liable  to  prove  serious  as  secondary  abscesses,  which  develop 
in  the  liver,  apparently  from  the  transmission  of  the  amoeba  coli 
through  the  portal  capillaries.  Abscess  of  the  liver  occurs  in  about 
one-iifth  of  all  cases  of  tropical  dysentery. 

Symptoms. — The  location  of  the  inflammatory  action  deter- 
mines, considerably,  the  character  of  the  symptoms.  In  a  large 
majority  of  all  the  cases  the  lower  part  of  the  colon  and  the  rectum 
are  principally  involved,  and  the  symptoms  are  more  local  than  con- 
stitutional, while,  if  the  upper  colon  is  exclusively  involved,  as  is 
sometimes  the  case,  there  are  few  local  symptoms,  while  such  consti- 
tutional manifestations  as  chill  and  febrile  action  are  marked. 

In  that  form  which  affects  the  lower  portion  of  the  large  gut  tor- 
mina and  teuesmus  are  frequent  and  urgent  symptoms,  the  periods 
of  tenesmus  being  attended  by  the  evacuation  of  a  tenacious,  glairy 
mucus  resembling  the  white  of  an  ego;  in  appearance  and  consistency, 
and  being  more  or  less  tinged  with  blood.  The  blood  varies  in 
quantity,  sometimes  being  mere  streaks  of  pink  color  in  the  clear 
mucus,  and  in  other  cases  constituting  the  principal  portion  of  the 
stool.  The  tenesmus  is  sometimes  so  severe  as  to  cause  extreme 
suffering,  the  patient  remaining  constantly  on  the  stool  or  bed-pan, 
straining,  as  though  there  were  a  foreign  body  in  the  rectum  to  be 
evacuated,  and  returning  almost  immediately  after  leaving  it,  in 
response  to  the  intense  dragging  sensation  in  the  rectum.  The  tor- 
mina or  griping  is  usually  correspondingly  severe,  the  pain  ranging 
along  the  course  of  the  colon,  but  being  most  common  along  the  trans- 
verse colon  just  above  the  umbilicus.  The  rectum  is  usually  the 
seat  of  severe  burning  pain,  arid  the  rectal  mucous  membrane  is  sen- 
sitive to  the  touch  of  the  finger,  a  rectal  speculum  or  the  tube  of  a 
syringe.  Sometimes,  especially  in  children,  there  is  complete  pro- 
lapse of  the  rectum  during  the  tenesmus,  and  the  anus  in  most  cases 


428  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

presents  a  purplish,  swollen,  ecchymotic  appearance.  The  bladder 
and  urethra  sympathize,  and  the  rectal  evacuation  may  be  accom- 
panied by  the  passage  of  a  few  drops  of  scalding  urine  accompanied 
by  vesical  tenesmus.  Fecal  material  may  appear  among  the  mucus 
during  the  first  evacuations,  and  often  the  disease  begins  with  a  fec- 
ulent diarrhoea;  but  soon  there  is  constipation,  the  evacuations  being 
limited  to  blood  and  mucus  at  first,  with  muco-purulent  passages  at 
a  later  stage  of  the  disease.  There  may  be  from  ten  to  two  hun- 
dred evacuations  in  twenty-four  hours. 

There  are  more  or  less  constitutional  symptoms  which  attend, 
and  sometimes  precede,  the  local  disturbance.  Sometimes  there  is 
loss  of  appetite,  furred  tongue,  nausea,  headache,  dry  skin  and  alter- 
nating diarrhoea  and  constipation  for  several  days  prior  to  the  devel- 
opment of  the  disease  proper.  As  the  dysentery  becomes  developed 
the  temperatures  rises  to  102°  or  103°  F.,  and  it  may  rise  as  high  as 
105°.  If  the  upper  portion  of  the  colon  is  exclusively  involved  the 
disease  may  be  ushered  in  with  a  marked  chill,  though  when  the  re- 
gion of  the  rectum  is  principally  involved  this  is  rare.  Typhoid 
symptoms  are  common  in  epidemic  dysentery,  and  the  patient  be- 
comes delirious,  the  delirium  usually  being  of  the  muttering,  somno- 
lent variety,  the  evacuations  being  dark,  resembling  prune  juice  in 
appearance,  often  containing  shreds  of  broken  down  mucous  mem- 
brane, and  emitting  a  cadaverous  odor.  The  tongue  becomes  brown 
and  dry,  the  patient  dozes  with  the  mouth  open,  the  pulse  becomes 
feeble  and  rapid,  the  respiration  hurried,  the  eyes  appear  sunken, 
and  serious  prospects  seem  to  be  in  store. 

Other  varieties  of  evacuations  than  those  already  described  are  the 
large,  watery,  feculent  stools  which  occur,  without  pain  or  tenesmus, 
when  the  dysentery  is  confined  to  the  upper  colon;  and  the  masses  of 
mushy,  boiled-sage  material  which  are  frequently  observed,  and 
which  consist  of  semi-digested  starch  granules  which  have  passed 
the  alimentary  canal  without  complete  disintregatioii.  The  stools 
of  amoeboid  dysentery  may  sometimes  consist  of  bloody  mucus,  but 
they  are  most  commonly  fluid  of  a  yellowish-gray  color,  in  which 
are  the  actively  moving  amoebae.  There  is  less  tormina  and  teues- 
rnus  than  in  catarrhal  dysentery,  and  hepatic  complication  is  more 
common. 

Malarial  complication  is  common  in  malarious  districts,  the  tor- 
mina and  frequency  of  the  evacuations  being  regularly  better  aud 
worse  at  stated  periods  of  the  twenty-four  hours,  corresponding  to 
the  exacerbations  and  remissions  of  a  malarial  fever. 

Scrobutic  dysentery  is  a  complication  of  dysenteric  inflammation 
with  the  ordinary  symptoms  of  scurvy.  In  this  form  profuse  hemor- 


DISEASES  OF  THE  INTESTINES.  429 

rhages  are  common,  and  fatal  results  are  extremely  liable  to  occur 
within  a  few  days  after  the  onset. 

Diagnosis. — There  is  little  danger  of  confounding  dysentery 
with  acute  proctitis,  as  there  is  scant  evacuation  in  that  disease,  no 
elevation  of  temperature,  and  little  disturbance  of  digestion.  The 
long-continued  intestinal  obstruction  and  general  marasmus  would 
distinguish  rectal  cancer.  In  diarrhoea  complicated  with  hemor- 
rhoids there  might  be  rectal  tenesmus  and  colicky  pains,  but  there 
would  be  an  absence  of  febrile  symptoms,  and  an  examination  would 
detect  the  exciting  cause  of  the  tenesmus  in  the  hamorrhoidal 
tumors. 

Prognosis. — Catarrhal  dysentery  of  non-malignant  type  is  usu- 
ally a  disease  of  favorable  prospects  unless  bunglingly  treated  or  the 
patient  has  advanced  far  in  years.  Epidemics  of  dysentery  are  some- 
times malignant  in  character,  and  the  prognosis  should  be  guarded, 
especially  in  elderly  persons. 

Diphtheritic  dysentery  is  a  much  more  severe  form  of  the  disease 
than  catarrhal  dysentery,  and  fatal  results  are  more  common,  especi- 
ally when  malignant.  Amoebic  dysentery  always  carries  with  it 
the  suggestion  of  possible  hepatic  abscess,  with  future  doubtful 
contingencies. 

Treatment. — The  treatment  of  dysentery  will  vary,  according 
to  the  demands  of  individual  cases.  Many  mild  sporadic  cases  may 
be  aborted  by  the  use  of  cathartic  doses  of  podophyllin.  Half  a  grain 
may  be  administered  to  an  adult  at  a  dose,  and  repeated  every  three 
or  four  hours  until  its  cathartic  action  is  manifested.  When  this 
passes  off  the  disease  will,  in  favorable  cases,  have  been  arrested. 
Broken  doses  of  sulphate  of  magnesium  answer  a  similar  purpose.  In 
all  cases  of  sporadic  dysentery  where  constipation  exists,  it  is  a  good 
plan  to  precede  other  treatment  with  the  use  of  a  cathartic. 

In  epidemics,  however,  this  treatment  will  fail,  and  often  there 
will  be  aggravation  from  it.  We  must  then  rely  upon  remedies, 
which  act  more  slowly,  but  which  conserve  normal  processes  and 
tend  to  restore  structure.  Opiates  and  astringents  are  worse  than 
no  treatment  at  all,  as  they  only  temporarily  palliate  the  pain  and 
lessen  the  discharges,  while  the  opiates  finally  aggravate  the  cousti- 
tional  difficulty  by  arresting  secretion,  and  the  astringents  increase 
the  local  inflammation.  The  pain  will  be  controlled  better,  in  the 
majority  of  cases,  by  minute  doses  of  colocynth  or  dioscorfn,  and  the 
local  inflammation  will  be  benefited  at  the  same  time.  A  combina- 
tion of  one  of  these  with  aconite  is  usually  valuable,  as  the  aconite 
controls  the  febrile  action  to  a  considerable  extent  and  at  the  same 
time  specifically  soothes  the  intestinal  mucous  membrane.  Ipecac  is 
also  a  valuable  remedy  here,  it  being  probably  the  most  generally 


430  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

applicable  agent  we  possess  in  intestinal  irritation  of  this  character. 
As  a  general  proposition  then  we  will  prescribe  in  ordinary  cases  the 
following  combination:  #  Specific  aconite  gtt.  vii-x,  specific  colo- 
cynth  gtt.  i-ii,  specific  ipecac  gtt.  x-xv,  water  fiv.  M.,  and  order  a 
teaspoonful  every  hour.  In  all  cases  the  patient  must  be  enjoined 
to  maintain  the  recumbent  posture,  using  the  bed-pan  and  avoiding 
straining,  as  aggravation  is  almost  certain  to  follow  unless  these 
injunctions  are  observed. 

Sometimes  colocynth  will  answer  alone,  especially  if  the  tormina 
is  the  leading  feature  of  the  case  and  there  is  much  blood  evacuated. 
Sometimes  the  tongue  is  pointed  and  reddened  at  the  tip  and  there 
is  constant  nausea  and  restlessness.  Here  we  will  expect  good 
results  from  a  combination  of  aconite  and  rlius  tox.,  especially  when 
the  nervous  disturbance  amounts  to  delirium.  Twenty  drops  of  spe- 
cific rhus  tox  to  ten  of  aconite  in  four  ounces  of  water,  teaspoonful 
at  a  dose,  will  be  appropriate  proportions.  Typhoid  dysentery  may 
demand  the  use  of  echinacea,  especially  where  there  is  evidence  of 
extensive  destruction  of  the  intestinal  mucous  membrane  as  suggested 
by  prune-juice  discharges  or  shreddy  material  in  the  stools  with 
cadaveric  odor.  The  dirty  pasty  coating  on  the  tongue  may  demand 
sulphite  of  sodium,  the  brown  coating  may  call  for  sulphurous  acid,  and 
the  beefy  tongue  may  call  for  muriatic  acid.  Baptisia  may  be  substi- 
tuted advantageously  for  echinacea  at  times  probably,  the  specific 
indications  recognized  for  it  by  many  being  the  prune-juice  character 
of  the  intestinal  discharges.  Excessive  hemorrhage  may  suggest  the 
need  of  rhus  aromatica,  and  persistent  ulceration,  as  indicated  by  the 
presence  of  pus  in  the  stools,  may  require  the  use  of  attenuations  of 
mercurius  corrosivus.  .The  rectal  injection  of  laudanum  constitutes 
an  old-fashioned  measure  which  had  better  be  avoided,  as  narcosis 
and  other  unpleasant  results  follow,  while  no  curative  action  can  be 
expected  from  it. 

The  use  of  hydrozone,  both  as  enemata  and  internally,  is  highly 
recommended  in  dysentery.  A  drachm  of  Marchand's  hydrozone 
may  be  added  to  four  ounces  of  sterilized  water  and  two  closes  made 
of  it,  one  being  taken  in  the  morning  and  the  other  in  the  evening. 
Where  it  seems  necessary  to  disinfect  the  lower  bowel  it  may  be  used 
as  an  enema,  the  patient  lying  on  the  right  side  to  facilitate  its  pass- 
age into  the  intestine.  High  injections  of  large  quantities  of  the 
same  strength  may  be  used  for  similar  purposes.  It  destroys  accum- 
ulated mucus  and  disease-germs,  thus  arresting  suppuration  and  fer- 
mentation, and  does  not  interfere  with  other  means. 

Periodicity  in  dysentery  should  be  recognized,  and  proper  anti- 
periodic  treatment  be  combined  with  the  measures  recommended  for 
the  control  of  the  dysenteric  symptoms. 


DISEASES  OF  THE  INTESTINES.  431 

The  diet  should  be  carefully  regulated.  Horlick's  malted  milk 
will  supply  every  purpose  when  it  can  be  taken  without  objection 
from  the  patient.  Scraped  raw  beef  is  preferred  by  some  and  may 
be  allowed  once  a  day  where  desired,  and  plain  milk,  boiled  and 
diluted  with  lime-water  to  prevent  hard  curds  is  excellent.  Some 
allow  the  albumen  of  raw  egg,  beaten  in  sherry  wine.  Starchy  food 
should  not  be  given,  as  the  digestion  of  starch  seems  to  be  interfered 
with  during  the  disease.  The  quantity  of  food  allowed  should  be 
very  small  at  one  time,  and  no  cold  food  should  be  taken,  the 
drinks  also  consisting  of  warm  mint  tea  and  other  bland  decoctions 
or  infusions  administered  warm.  Keturn  to  solid  food  should  be 
gradual,  and  fruits  should  be  taken  with  caution  for  a  time  and  only 
after  having  been  cooked. 

CHOLERA  MOBBUS. 

Synonyms. —  Cholera  Nostras;  Sporadic  Cholera;  English 
Cholera. 

Definition. — An  emetoi-catharsis,  characterized  by  simultane- 
ous vomiting  and  purging  of  watery  material,  with  intense  thirst, 
pain  in  the  abdomen  and  legs,  coldness  in  the  extremities  and 
prostration. 

Etiology. — Cholera  morbus  is  a  disease  of  hot  weather,  and  is 
usually  due  to  some  disturbance  of  the  digestive  processes  from  the 
eating  of  unripe  or  over-ripe  fruits  or  vegetables  in  season  at  such 
times,  though  indigestible  food  may  excite  it  in  susceptible  persons 
at  any  time  of  the  year.  Sudden  checking  of  perspiration  by  expos- 
ure to  draughts  while  heated,  or  by  drinking  iced  liquids,  may  bring 
it  on,  and  contaminated  drinking  water  doubtless  causes  it,  hot,  dry 
weather  being  the  time  when  the  source  of  water  supply  is  most  apt 
to  suffer  from  stagnation.  Sometimes  the  disease  seems  to  assume 
epidemic  proportions,  though  it  is  usually  sporadic.  Males  are 
more  frequently  affected  than  females,  and  extreme  old  age  provides 
considerable  exemption. 

Pathology. — This  varies  considerably,  there  sometimes  being 
no  ocular  evidence  of  structural  change  or  vascular  disturbance, 
while  again  evidence  of  acute  enteritis  may  be  present.  Cerebral 
anaemia  is  sometimes  found  upon  autopsy,  and  effusion  into  the  ven- 
tricles may  attend.  Few  opportunities  of  autopsy  have  been  afforded, 
as  the  disease  is  seldom  fatal,  and  little  study  therefore  has  been 
made  of  post-mortem  appearances.  As  the  disease  is  of  short  dura- 
tion, what  changes  take  place  are  liable  to  be  largely  vascular. 

Symptoms. — The  attack  usually  comes  on  at  night,  and  is  an- 
nounced bv  vomiting  and  purging,  this  sometimes  being  preceded  by 


432  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

several  hours  of  premonitory  symptoms,  such  as  nausea,  headache 
and  vague  abdominal  distress.  The  vomiting  is  violent  and  pro- 
jectile, and  comes  on  suddenly  and  without  premonition,  and  the 
retching  is  often  accompanied  by  simultaneous  gushes  of  serous  diar- 
rhoaa  of  acid  or  bilious  character.  Though  the  patient  is  thirsty  and 
drinka  greedily  the  fluid  is  immediately  rejected,  and  solid  food  is 
also  vomited  as  soon  as  swallowed.  Gushing  evacuations  from  the 
bowels  follow  one  another  in  quick  succession,  the  evacuations  being 
watery  and  of  a  mouse-like  odor.  The  evacuations  are  sometimes 
large  and  light  colored,  and  at  others  small  and  dark  in  appearance. 
Abdominal  pain  accompanies  and  precedes  the  evacuations  and  vom- 
iting, and,  in  severe  cases,  cramps  in  the  lower  extremities,  especially 
in  the  calves  of  the  legs  and  feet,  attend.  The  urinary  discharge 
becomes  arrested,  this  probably  being  due  to  excessive  drainage 
through  the  bowels,  though  albumin  and  desquamated  epithelium 
may  be  found  in  the  renal  secretion.  Prostration  may  become 
marked,  and  it  may  seem  as  though  a  speedily  fatal  termination 
might  be  imminent,  but  after  a  few  hours  the  symptoms  suddenly 
and  spontaneously  abate  and  the  patient  recovers  without  interrup- 
tion, being  apparently  as  well  as  usual  in  a  day  or  two.  In  some 
cases,  however,  the  pulse  becomes  feeble  and  flickering,  the  respira- 
tion and  voice  feeble  and  the  surface  icy  cold,  and  the  patient  passes 
into  a  stage  of  collapse  and  dies,  the  mind  being  clear  throughout. 
Febrile  symptoms  are  absent,  except  when  pyrexial  action  attends  a 
sh<  rt  period  of  convalesence,this  sometimes  occurring,  the  symptoms 
being  mildly  typhoid  in  character,  the  condition  being  termed  the 
reactionary  fever.  The  stools  usually  become  normal  within  a  day 
after  the  attack. 

Diagnosis. — There  is  little  danger  of  confounding  this  disease 
with  anything  except  Asiatic  cholera,  and  this  would  occur  only 
when  Asiatic  cholera  was  prevailing  as  an  epidemic.  In  Asiatic 
cholera  it  is  to  be  remembered  that  there  is  no  fecal  odor  to  the 
stools,  which  are  rice-water  in  appearance  from  the  commencement, 
while  in  cholera  morbus  the  stools  are  at  first  fecal.  Irritative 
poisoning  may  present  us  with  symptoms  similar  to  those  of  chol- 
era morbus,  but  the  history  of  the  case  will  probably  afford  light  on 
the  subject;  the  mouth  and  pharynx  are  liable  to  be  hypersemic,  and 
the  evacuations  will  contain  more  or  less  blood,  a  condition  never 
found  in  cholera  morbus.  Analysis  of  the  vomited  material  may 
decide  the  question,  through  detection  of  the  presence  of  corrosive 
drugs. 

Prognosis. — Cholera  morbus  is  seldom  fatal.  Though  a  severe 
disease  it  is  likely  to  terminate  spontaneously  is  a  few  hours;  though 
treatment  will  usually  arrest  it  promptly  and  prevent  a  very  unpleas- 


DISEASES  OF  THE  INTESTINES.  433 

ant  experience  for  the  patient.  Elderly  persons  are  the  ones  in 
whom  there  is  the  most  danger  of  serious  results,  and  if  collapse  or 
the  algid  state  should  be  developed  the  danger  is  imminent.  The 
prevalence  of  an  epidemic  of  intestinal  disease  coincident  with  an 
attack  increases  its  gravity. 

Treatment. — The  treatment  of  cholera  morbus  is  simple  and 
effective.  As  soon  as  the  stomach  and  bowels  are  ridden  of  irritat- 
iug  food  and  fecal  material,  and  even  before,  the  following  prescrip- 
tion may  be  administered  in  teaspoonful  doses  every  fifteen  minutes, 
until  the  vomiting  and  purging  cease:  R  Specific  rhus  tox.  gtt.  xv, 
Lloyd's  aconite  gtt.  x,  sterilized  water  fiv.  Mix. 

The  following  prescription  may  be  useful  to  destroy  fermentative 
products  and  cleanse  the  alimentary  canal  of  irritating  material: 
R  Marchand's  hydrozone  31,  sterilized  water  fii.  Mix,  and  admin- 
ister at  a  single  dose. 

Heating  and  stimulating  applications  to  the  extremities  may  be 
required  when  there  is  great  coldness  of  the  surface  with  other 
symptoms  of  collapse,  and  in  malarial  districts  recovery  from  the 
active  symptoms  should  be  followed  by  the  administration  of  fif- 
teen-drop doses  of  the  green-plant  tincture  of  grindelia  squarrosa, 
repeated  three  or  four  times  daily  and  continued  for  a  week  or  more. 

CANCER  OF  THE  INTESTINE. 

PRIMARY  cancer  of  the  intestine  occurs  in  from  four  to  eight 
per  cent  of  all  cases  of  cancer,  the  colon  being  most  frequently  in- 
volved, the  rectum  being  the  next  most  common  seat  of  location,  then 
the  anus,  caecum  and  sigmoid  flexure.  The  duodenum  and  jeju- 
num, finally,  are  involved,  coming  last  in  order  of  frequency. 

Etiology. — Intestinal  cancer  seldom  arises  before  middle  age, 
though  it  occasionally  occurs  before  thirty.  Its  usual  subjects  are 
between  forty  and  sixty,  both  sexes  being  liable  to  it,  though  it 
is  stated  that  rectal  caucar  is  more  common  among  males  than 
females.  It  is  impossible  to  ascribe  a  specific  etiological  factor, 
long-continued  irritation  probably  predisposing  to  it.  Thus,  a  per- 
son who  has  long  been  the  subject  of  rectal  ulceration,  hemor- 
rhoids, pockets  or  papillae  is  more  liable  to  finally  develop  rectal 
cancer  than  one  who  has  been  previously  without  irritation  there. 
The  sigmoid  flexure  and  caecum,  on  account  of  peculiar  location 
and  shape,  are  certainly  more  subject  to  irritation  from  fecal  move- 
ment than  some  other  parts  of  the  intestinal  canal.  Without  doubt 
the  pernicious  habit  of  administering  cholagogues,  which  has  been 
in  vogue  so  long,  has  something  to  do,  occasionally,  at  least,  with 

29 


434  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

the  occurrence  of  cancer  of    the  upper    portion    of    the    intestinal 
canal. 

Pathology. — The  growth  commonly  arises  in  the  mucous  mem- 
brane and  develops  in  the  submucous  tissues,  the  infiltration  ex- 
tending around  the  intestine  and  forming  a  baud  of  constriction, 
which  narrows,  more  or  less,  the  calibre  of  the  gut.  The  cou- 
stricting  band  may  vary  from  an  inch  to  three  or  four  inches  iu 
width,  the  intestinal  wall  becoming  infiltrated  and  indurated  about 
the  narrowed  portion.  In  some  cases  there  may  be  projections 
of  ragged  masses  into  the  bowel,  especially  about  the  rectum,  and 
fungous  growths  may  project  from  the  anus.  Prior  to  ulceration, 
scirrhous  cancer  presents  a  firm,  smooth,  nodulated  appearance;  en- 
cephaloid,  a  soft,  vascular  aspect,  without  much  tendency  to  ulcer- 
ate or  obstruct  the  bowel.  When  ulceration  occurs,  scirrhous  is 
marked  by  smooth  ulcerations  with  hard,  deep  edges,  and  encepha- 
loid  by  fungoid  masses  which  spring  up  over  the  ulcerated  surface, 
interspersed  with  nodulated  and  lobulated  tumors.  In  many  cases 
scirrhous  and  encephaloid  may  be  mingled  in  the 
same  growth.  Secondary  cancer  is  apt  to  arise  in 
neighboring  organs,  and  the  rapid  growth  of  these 
may  obscure  the  symptoms  of  the  primary  tumor. 
The  liver  is  a  favorite  location  for  secondary  carci- 
nomatous  development,  and  when  this  occurs  the  in- 
testinal disease  may  come  to  nearly  a  standstill,  the 
concentration  of  pathological  energy  seeming  to  be 
transposed  to  the  seat  of  secondary  growth.  Stric- 
ture of  the  intestine  is  a  common  condition  in  scir- 
rhus,  and  distension  of  the  bowel  above  this  point 
from  impacted  feces  usually  attends.  Catarrh  of  the  intestinal 
mucous  membrane  in  the  neighborhood  of  the  cancer  is  common. 
Rapid  infiltration  of  the  mesentery  and  neighboring  organs  may 
bind  the  affected  part  to  surrounding  tissues,  dragging  and  confining 
various  parts  in  a  firm  mat;  perforation  may  ensue  from  rapid  ulcer- 
ation; fistulse  are  sometimes  formed  between  the  neighboring  vis- 
cera; hemorrhage  may  arise  from  destruction  of  branches  of  intestinal 
arteries,  and  various  other  sequelae  and  complications  may  arise  from 
the  extension  of  the  cancerous  growth  to  new  localities. 

Symptoms. — The  symptoms  may  best  be  described  by  dealing 
with  various  portions  of  the  intestine  separately. 

Duodenal  &ndjejunal  cancer  are  marked  by  symptoms  similar  to 
those  of  cancer  in  the  pylorus.  There  is  often  vomiting,  though 
it  comes  on  several  hours  after  eating.  The  ejected  material  is  cof- 
fee-ground in  appearance,  there  is  a  movable,  pulsating  tumor  in 
the  epigastrium  resembling  that  of  pyloric  cancer  to  the  touch,  and 


DISEASES  OF  THE  INTESTINES.  435 

there  is  cancerous  cachexia  with  or  without  marked  icteric  symp- 
toms, due  to  obstruction  in  the  biliary  duct.  Hemorrhages  mav 
occur  and  haematemesis  or  melaena  follow,  though  the  bleeding  is 
rarely  profuse. 

Cancer  of  the  caecum  is  signalized  by  pain  in  the  region  of  the 
caecum,  with  the  presence  of  a  prominent  tumor,  consisting  of  accu- 
mulated feces  and  cancerous  growth,  the  local  symptoms  being 
accompanied  by  debility,  waxy  color  and  other  constitutional  evi- 
dences of  cancer.  Manipulation  may  assist  the  retarded  feces  past 
the  point  of  obstruction  and  lessen  the  size  of  the  tumor,  but  the 
cancerous  deposit  is  still  perceptible  on  palpation.  The  obstruc- 
tion is  progressive,  and  permanent  impaction  of  feces  finally  ensues. 
Tympauitic  dullness  is  elicited  by  percussion  over  the  tumor. 

Rectal  cancer  and  cancer  of  the  sigmoid flexure  present  symptoms 
so  much  in  common  that  differentiation  is  not  easy.  Constipation, 
due  to  stricture,  is  usually  the  first  cause  of  complaint,  the  bowels 
moving  with  difficulty,  the  faeces  being  thin  and  ribbon-like,  the 
evacuations  attended  by  severe  burning  pain  and  tenesmus.  The 
pain  is  often  most  severe  in  the  sacral  region,  and  from  here  it  radi- 
ates along  the  sciatic  nerves  into  the  lower  extremities.  This  is 
darting  in  character,  and  may  be  so  intense  as  to  render  existence 
miserable.  In  some  cases  instead  of  constipation  there  may  be  an 
irregular  diarrhoea,  signalized  by  the  passage  of  faecal  material  mixed 
with  mucus,  pus  and  blood,  the  evacuations  being  attended  by 
severe  tenesmus  and  pain.  Fistulae  may  be  established  into  the 
bladder,  vagina  or  urethra,  and  liquid  faeces  may  escape  through 
these  channels.  As  the  sphincter  becomes  involved  it  loses  its 
function,  and  liquid  faeces  and  cancerous  products  dribble  through 
to  excoriate  the  parts  and  render  the  surroundings  offensive.  On 
examination  the  affected  part  will  usually  be  found  to  be  obstructed 
by  a  firm,  fibrous  band,  through  which  it  may  be  difficult  to  pass 
even  a  small  gum-elastic  bougie,  on  account  of  the  rigid  and  tortuous 
character  of  the  passage.  However,  sometimes  the  rectal  walls  are 
relaxed  and  dilated.  In  epithelioma  of  the  rectum  there  may  not 
be  much  obstruction  for  a  long  time  after  its  first  development,  pain, 
cachexia  and  obstruction  coming  on  only  at  a  late  period.  Obstruc- 
tion of  the  colon  is  indicated  by  distension  of  the  organ,  with  hard- 
ened faeces,  its  course  being  traceable  under  the  fingers  through  the 
attenuated  abdominal  walls.  Wh^n  the  sigmoid  flexure  or  upper 
portion  of  the  colon  is  the  seat  of  infiltration,  the  pain  may  be 
located  in  the  left  iliac  fossa  and  loins  much  of  the  time,  and  when 
in  the  rectum  in  the  upper  part  of  the  thighs,  testes  and  loins. 

In  most  cases  of  intestinal  cancer  cachexia  develops  early.  The 
patient  rapidly  loses  flesh  and  strength,  there  is  occasional  vomiting, 


436  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

and  constipation  is  soon  marked,  though  cancer  high  up  in  the 
colon  may  be  attended  by  diarrhoea.  The  skin  assumes  a  dirty 
greenish  or  waxy  pallor  and  becomes  dry,  harsh  and  leathery, 
remaining  wrinkled  for  several  seconds  when  pinched  into  rolls;  the 
hair  is  dry  and  brittle  and  the  pulse  small  and  feeble.  Emaciation 
progresses  swiftly,  death  from  exhaustion  being  a  frequent  cause 
of  fatal  termination.  Profuse  hemorrhage  is  rare  in  any  form  of 
intestinal  cancer. 

Diagnosis. — The  unmistakable  symptoms  of  intestinal  cancer 
are  pain,  cachexia,  constipation  and  the  presence  of  a  tumor  within 
the  abdominal  cavity;  though  intestinal  cancer  may  run  its  course 
without  the  detectable  tumor.  Duodenal  cancer  is  so  closely  asso- 
ciated with  the  pylorus  and  pancreas  that  confusion  may  arise  as 
to  identity.  The  character  and  time  of  occurrence  of  vomiting  after 
meals  and  the  fact  that  the  tumor  is  more  movable  than  that  of 
pyloric  or  pancreatic  tumor  will  serve  some  diagnostic  purpose.  The 
pancreas  is  more  deeply  seated  and  less  movable,  and  vomiting  is 
not  so  liable  to  occur  when  it  is  cancerous.  A  pulsating  duodenal 
cancer  may  be  distinguished  from  aneurism  of  the  abdominal  aorta 
by  the  fact  that  the  abdominal  aneurism  will  transmit  its  disturb- 
ance to  the  femoral  artery,  while  the  pulsations  of  that  vessel 
remain  undisturbed  in  duodenal  cancer.  In  cancer  of  the  small  in- 
testine the  tumor  may  be  more  or  less  displaced  by  adhesions  and 
contracting  bands,  assisted  by  the  weight  of  the  tumor,  and  this 
is  also  true  of  the  transverse  colon;  but  the  caecum,  sigmoid  flexure 
and  ascending  colon  are  firmly  fixed  and  not  so  liable  to  be  misplaced. 
In  rectal  cancer,  after  the  ulceration  has  begun,  the  peculiar  foetid 
odor  of  the  discharge  is  important  in  making  a  diagnosis. 

Prognosis. — The  prognosis  is  invariably  unfavorable,  the  patient 
succumbing  within  from  eighteen  months  to  four  years,  depending 
on  the  amount  of  cachexia  and  intestinal  obstruction.  Where  sur- 
gical measures  are  adopted  early  in  rectal  cancer  life  may  sometimes 
be  prolonged. 

Treatment. — Where  duodenal  cancer  occasions  pyloric  obstruc- 
tion benefit  may  be  derived  by  the  use  of  hydrozone  to  cleanse  the 
stomach  of  mucus  and  other  accumulation,  and  this  may  be  followed 
by  lavage.  In  any  event  the  use  of  hydrozone  provides  for  the 
destruction  of  purulent  accumulation  in  the  intestine  and  removes 
accumulated  mucus  occasioned  by  the  catarahal  condition  of  the 
neighboring  mucous  membrane.  Bovinine  supports  the  strength  and 
lessens  the  pain,  though  echinacea  is  the  most  promising  agent  we 
possess  for  the  purposes  of  alleviating  the  pain  of  cancer  (ten  or  fif- 
teen drops  of  a  prime  preparation  every  three  or  four  hours). 
Chelidonium  promises  much  toward  a  radical  cure  early;  ten  drops 


DISEASES  OF  THE  INTESTINES.  437 

of  the  homeopathic  tincture  or  specific  medicine  four  times  daily. 
Where  the  rectum  is  the  part  affected  an  operation  for  the  removal 
of  the  cancerous  mass  may  be  undertaken  early  when  the  growth  is 
low,  and  obstruction,  in  cases  in  which  this  seems  inexpedient,  may 
be  counteracted  through  the  establishment  of  an  artificial  anus  by 
colotomy. 

The  patient  should  remain  quietly  in  bed  to  insure  a  minimum 
amount  of  peristalsis,  and  the  food  should  be  liqu  d  in  form  and  con- 
centrated in  quality. 

INTESTINAL  OBSTRUCTION. 

Definition. — A  mechanical  impediment  to  the  onward  move- 
ment of  the  intestinal  contents  from  compression,  twisting,  invag- 
ination  of  the  bowel,  or  from  the  presence  of  foreign  bodies  in 
the  passage. 

Etiology  and  Pathology. — Internal  strangulation  of  the  in- 
testine is  the  cause  of  at  least  a  third  of  the  cases  of  intestinal 
obstruction  which  occur  in  adults.  Adhesive  bands  connecting 
portions  of  the  intestine  to  the  abdominal  wall  may  form  loops,  into 
which  a  section  of  the  intestine  may  enter  and  finally  become  strang- 
ulated, Meckel's  diverticulum  may  adhere  to  the  abdominal  wall 
to  form  a  loop  of  this  character,  and  such  nooses  frequently  result 
from  abdominal  section,  a  portion  of  the  bowel  remaining  adher- 
ent to  the  abdominal  wound,  or  the  pedicle  of  a  tumor  serving  to  aid 
in  forming  an  entangling  loop.  Other  openings,  such  as  the  fora- 
men of  Winslow,  or  accidental  perforations  in  the  mesentery 
or  omentum,  may  afford  opportunities  for  strangulation. 
This  accident  is  most  likely  to  occur  to  the  small  intestine. 
A  more  frequent  cause  among  children  is  intussusception  or 
invagiuation  of  the  intestine,  the  bowel  being  telescoped  from 
above  downward,  so  that  from  an  inch  to  a  foot  of  the  gut  is 
incased  within  the  same  length  below.  The  ileo-caecal  valve 
ig  mos^  commonly  telescoped  into  the  colon,  though  the  acci- 
Ttcs'  dent  may  occur  to  any  portion  of  the  bowel,  the  condition 
being  due  to  irregular  peristaltic  action.  As  in  strangulation  the 
part  soon  becomes  congested  and  swollen,  and  peritoneal  exudation 
agglutinates  the  invaginated  part  so  completely  that  reduction  be- 
comes impossible,  the  inner  section  sometimes  separating  and  being 
discharged  per  rectum.  Necrosis  and  sloughing  of  the  entire  affected 
part  is  the  most  probable  termination.  This  accident  is  more  com- 
mon among  males  than  females,  and  more  than  fifty  per  cent  of  the 
cases  are  among  children. 

Volvulus,  or  twisting  of  the  bowel   upon  itself,  is  an  occasional 


438  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

cause  of  intestinal  obstruction.  This  accident  is  most  liable  to 
occur  about  the  sigmoid  flexure,  a  relaxed  state  of  the  mesentery 
favoring  such  circumstance,  and  half  a  turn  being  sufficient  to  cause 
obstruction.  Sometimes  two  coils  of  intestine  unite  to  form  a  knot, 
which  becomes  fixed  and  permanently  agglutinated.  In  old  persons 
shrinking  of  the  mesentery  may  give  rise  to  twisting  of  the  sigmoid 
flexure,  and  resultant  obstruction. 

Foreign  bodies  in  the  intestine  sometimes  become  permanently 
lodged  and  so  impacted  as  to  cause  serious  obstruction.  False  teeth 
(accidentally,  or  purposely  swallowed — by  the  insane)  may  cause  fatal 
obstruction,  the  ileo-caecal  valve  being  the  point  which  offers  the 
most  resistance.  Sometimes  buttons,  nickels  and  other  coins  are 
swallowed  by  children  and  cause  blocking  of  the  intestinal  passage, 
though  such  accidents  in  children  are  singularly  free  from  serious 
results,  the  foreign  material  most  commonly  appearing  in  the  stools 
after  a  safe  passage  through  the  gut.  Large  gall-stones  some- 
times block  the  passage  and  give  rise  to  serious  obstruction.  Some 
drugs,  as  bismuth,  magnesia  and  other  powders,  may  combine  with 
faecal  material  and  form  firm  masses,  which  produce  obstruction. 

Stricture  of  the  bowel  from  cancerous  infiltration  has  already 
been  referred  to.  Pressure  from  tumors,  as  well  as  stricture  from 
chronic  conditions,  is  progressive  and  gradual  in  character,  and  the 
pathological  changes  are  slow  in  developing  and  the  symptoms 
are  not  at  first  urgent,  as  in  strangulation,  intussusception  and 
volvulus. 

Symptoms. — Sudden  obstruction  of  the  bowel  usually  occurs 
while  the  patient  is  walking  about,  and  is  announced  by  severe  col- 
icky pain,  which  is  localized  and  intermittent.  As  the  pain  con- 
tinues it  becomes  more  steady  in  character  and  increases  in  severity 
in  its  original  location,  while  it  is  soon  more  or  less  diffused 
throughout  the  abdomen.  Vomiting  soon  begins  and  becomes  con- 
stant and  distressing,  the  vomited  material  first  consisting  of  the 
contents  of  the  stomach,  then  of  bile  and  mucus,  and  later  of  sterco- 
raceous  material.  Obstinate  hiccough  arises  after  the  vomiting  has 
continued  for  a  time,  and  the  vomiting  may  finally  cease  entirely  to 
be  replaced  by  hiccough,  which  continues  until  a  fatal  termination. 
Stercoraceous  material  is  vomited  only  when  the  obstruction  arises 
below  the  upper  third  of  the  ileum.  An  intestinal  evacuation  may 
occur  immediately  after  the  obstruction  arises,  the  operation 
emptying  the  bowel  below  the  point  of  obstruction,  but  constipa- 
tion afterward  attends,  all  efforts  to  produce  an  evacuation  prov- 
ing futile.  Tenesmus  may  arise  when  the  obstruction  is  low  in  the 
alimentary  canal,  and  blood  and  mucus  may  be  discharged  when 
there  is  invagination.  Tympanites  suggests  the  location  of  the 


DISEASES  OF  THE  INTESTINES.  439 

obstruction  low  in  the  alimentary  canal.  There  is  little  pain  on 
pressure  at  first,  but  later  the  entire  abdominal  surface  becomes 
intensely  sensitive. 

The  face  presents  an  anxious,  pallid  appearance,  the  surface  and 
extremities  are  cold,  the  patient  lies  on  his  back  with  the  lower  limbs 
drawn  up  to  avoid  strain  upon  the  abdominal  muscles  and  carefully 
jivoids  motion  for  fear  of  exciting  vomiting  and  abdominal  pain. 
Enteritis  of  violent  character  attends  volvulus.  The  mind  is  clear 
to  the  last. 

Diagnosis. — In  diagnosing  intestinal  obstruction  it  is  to  be 
recollected  that  intussusception  is  most  liable  to  occur  in  children,  and 
when  a  child  who  has  been  previously  well  is  seized  with  sudden  and 
severe  pain  followed  by  vomiting  and  constipation  succeeded  by  dis- 
charges of  bloody  mucus  with  tenesmus,  the  pain  and  vomiting  being 
urgent  and  persistent,  there  are  good  grounds  for  suspecting  intes- 
tinal obstruction  of  this  character.  If,  in  addition  to  these  symptoms, 
a  sausage-shaped  tumor  appears  in  the  region  of  the  ascending  or 
transverse  colon  within  a  day  or  two,  the  diagnosis  is  still  more  clear. 
In  this  form  faecal  vomiting  is  not  so  common  as  in  some  other  varie- 
ties of  intestinal  obstruction. 

Sudden  attacks  of  similar  character  in  adults  with  paroxysmal 
pain  at  a  fixed  point,  attended  by  faecal  vomiting  and  rapidly  devel- 
oping tympanites  with  constipation,  will  point  decidedly  to  internal 
strangulation.  A  history  of  prior  injury,  surgical  operation  or  peri- 
tonitis, suggesting  the  presence  of  adhesions  forming  entangling 
loops,  will  assist  in  a  rational  conclusion  as  to  condition.  The  pres- 
ence of  a  tumor  is  not  to  be  expected  here  and,  though  constipation 
is  absolute,  there  will  not  be  tenesmus  or  bloody  discharges. 

Volvulus  is  more  obscure  in  character,  though  if  the  sigmoid  flex- 
ure is  involved  it  may  be  suspected  by  the  pain  in  that  vicinity,  the 
marked  tenesmus,  and  mucus  and  bloody  evacuations  during  the 
advanced  stage. 

Obstruction  by  foreign  bodies  is  liable  to  afford  a  history  of  the 
swallowing  of  some  indigestible,  bulky  article,  and  the  lodgment  is 
most  liable  to  be  made  at  the  ilio-caecal  valve.  In  faecal  impaction 
there  is  a  firm,  hard  tumor  in  the  csecal  region,  without  vomiting 
until  at  a  late  period,  with  prior  history  of  constipation.  Peritonitis 
is  attended  by  rise  in  temperature,  while  in  intestinal  obstruction 
the  temperature  is  not  elevated,  and  is  likely  to  "be  subnormal. 
Vomiting  is  not  so  liable  to  attend  peritonitis  as  obstruction,  and 
in  peritonitis  there  is  marked  abdominal  tenderness  early.  In 
hepatic  colic  the  pain  radiates  from  the  right  hypochondriac  region, 
the  patient  is  jaundiced,  and  there  are  clay-colored  stools  with  con- 
stipation but  not  obstruction,  and  the  urine  contains  bile.  There  is 


440  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

no  faecal  vomiting  here  and  no  tympanites.  In  renal  colic  the  pain  radi- 
ates from  the  lumbar  region  along  the  ureters  to  the  penis  and 
testes,  and  there  is  no  interruption  to  normal  intestinal  evacuation. 
A  concealed  inguinal  or  femoral  hernia  may  be  mistaken  for  intes- 
tinal strangulation,  unless  a  careful  examination  of  the  suspected 
rupture  be  made. 

Prognosis. — This  will  vary,  according  to  the  acuteness  of  the 
attack.  Chronic  obstruction  in  the  adult  may  exist  for  many  weeks 
before  fatal  termination  ends  the  scene,  while  intussusception  of  the 
bowel  in  a  weakly  child  may  cause  death  within  a  few  hours.  Vol- 
vulus and  internal  strangulation  are  more  rapidly  fatal  than  intus- 
susception, and  obstruction  by  large  gall-stoues  and  enteroliths  is 
more  rapidly  fatal  than  stricture,  compression  or  intussusception. 
There  is  possibility  that  sloughing  may  occur  in  intussusception 
and  the  lower  portion  of  the  invaginated  bowel  be  cast  off,  with 
union  of  the  remainder  with  the  regular  course  of  the  alimentery 
canal,  with  recovery,  and  there  is  a  possibility  that  it  may  be 
reduced  to  its  normal  position  if  effort  be  made  in  the  right  direction 
before  the  parts  become  agglutinated.  On  the  whole,  however,  the 
prognosis  is  almost  invariably  unfavorable  to  recovery. 

Such  complications  as  enteritis,  peritonitis,  perforation,  ulcera- 
tion,  gangrene,  septicaemia,  fistula  and  phlebitis  are  among  the 
probabilities. 

Treatment. — Under  no  circumstances  is  attempt  to  force  a  faecal 
evacuation  by  catharsis  advisable.  If  there  be  simply  faecal  accumu- 
lation the  proper  use  of  enemata  assisted  by  the  salt-water  rectal 
electrode  will  more  assuredly  remove  the  impaction  than  the  action 
of  cathartics,  and  its  use  is  permissible  when  there  is  actual  obstruc- 
tion. This  measure  should  be  tried  with  both  galvanism  and  farad- 
ism,  if  necessary,  the  faradic  current  increasing  inverted  peristaltic 
action  and  thus  favoring  the  relief  of  volvulus  and  invagination.  A 
strong  decoction  of  cimicifuga  root  is  relaxing  and  quieting  to  the 
intestines,  and  should  be  given  in  wine-glassful  doses  every  hour  for 
a  few  hours  where  obstruction  is  suspected.  Inversion  of  the  patient, 
the  body  being  elevated  by  the  heels  to  nearly  the  upright  position 
aud  maintained  there  for  a  time,  is  highly  recommended  in  intussus- 
ception and  volvulus,  and  in  this  position  copious  enemata  of  warm 
water  should  be  tried.  Air,  introduced  by  attaching  a  rectal  tube  to 
a  siphon-bottle  of  carbonated  water,  may  be  forced  into  the  bowel, 
this  sometimes  serving  to  relieve  an  invagination  or  volvulus,  though 
there  is  danger  of  rupturing  the  gut  by  incautious  application  of  the 
measure.  After  forty-eight  hours  adhesions  are  presumed  to  have 
taken  place,  when  attempts  to  remove  the  fixation  will  be  fruitless. 
Opiates  early  are  highly  recommended,  though  with  doubtful  philos- 


DISEASES  OF  THE  INTESTINES.  44i 

ophy;  but  at  a  late  stage  they  may  be  administered  freely  to  allay 
the  pain.  Abdominal  section  is  justifiable  where  the  diagnosis  is 
confirmed,  and  it  should  not  be  delayed  until  the  strangulation 
has  gone  on  to  gangrene. 

INTESTINAL  HEMORRHAGE. 

Synonyms. — Euterorrhagia. 

Etiology. — Among  the  principal  causes  of  intestinal  hemorrhage 
are  intestinal  ulcers  attended  by  erosion  of  vessels,  and  cirrhosis  or 
atrophy  of  the  liver  causing  obstruction  of  the  portal  circulation. 
Erosion  may  also  be  caused  by  strong  drugs,  and  venous  obstruction 
may  arise  from  pressure  by  tumors,  foreign  bodies  or  hardened 
faeces.  Profuse  intestinal  hemorrhage  may  occur  from  the  rupture 
of  an  aneurism,  and  one  of  the  common  symptoms  of  internal  hemor- 
rhoids is  profuse  bleeding  from  the  bowel.  The  engorgement  due 
to  iuvaginatiou  and  volvulus  is  liable  to  be  attended  by  bloody  evacu- 
ations, as  also  are  severe  inflammations  of  the  intestinal  mucous 
membrane,  as  in  dysentery,  enteritis  and  typhoid  fever.  Embolism 
of  the  mesenteric  artery  may  be  a  cause  of  intestinal  hemorrhage. 
A  number  of  constitutional  diseases  may  originate  bleeding  from 
the  bowels.  Among  these  may  be  mentioned  purpura  hemorrhag- 
ica,  scorbutus,  pernicious  anaemia,  leukaemia,  pseudo-leukaemia,  sep- 
ticaemia, jaundice  and  phosphorus  poisoning.  The  aged  maybe  sub- 
ject to  passive  intestinal  hemorrhage  of  obscure  nature,  men  being 
more  liable  than  women.  Melaena  neonatorum,  or  hemorrhage  in 
new-born  children,  may  be  due  to  degeneration  of  the  arteries  from 
syphilitic,  fatty  or  amyloid  changes,  from  puerperal  infection  and 
from  haemophilia. 

Pathology. — When  examined  soon  after  death  the  intestinal 
mucous  membrane  may  be  hyperaemic  or  anaemic,  depending  upon 
the  amount  of  blood  discharged.  The  intestine  usually  contains 
small  clots  of  grumous  blood,  and  when  hemorrhage  occurs  from 
the  surface  of  ulcers  coagula  are  generally  found  adhering  to  them. 
When  the  hemorrhage  is  due  to  obstruction  of  the  portal  circulation 
there  is  usually  little  change  from  normal  in  the  appearance  of  the 
mucous  membrane. 

Symptoms. The  constitutional  symptoms  are  those  of  hemor- 
rhage in  general.  There  are  sensations  of  faintness,  coldness  of  the 
surface,  ringing  in  the  ears  and  syncope,  with  feeble  pulse,  pallor, 
and  coma  which  may  end  in  death.  Preceding,  attending  or  follow- 
ing these  symptoms,  there  is  an  evacuation  of  blood  from  the  bowels, 
and  this  may  be  attended  by  pain  or  other  abnormal  sensations, 


442  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

such,  for  instance,  as  though  warm  water  was  being  poured  into   the 
abdominal  cavity. 

The  blood  varies  in  color  and  consistency  as  it  comes  from  differ- 
ent portions  of  the  intestinal  tract.  That  which  issues  from  the 
walls  of  the  duodenum  is  black  and  tarry  in  appearance  and  tena- 
cious in  consistency.  That  from  the  ileum  is  usually  dark,  but  it 
is  brighter  than  that  from  the  duodenum,  and  returns  to  its  normal 
color  when  the  clots  are  dissolved  in  water.  The  blood  from  the 
large  intestine  is  usually  bright-red  and  fluid.  The  dark  color  of 
the  faeces  caused  by  hemorrhage  from  the  duodenum  is  not  to  be 
confounded  with  the  appearance  produced  by  eating  huckleberries 
or  taking  iron  or  bismuth.  The  quantity  may  vary  from  a  few  streaks 
in  the  faeces  in  some  cases  to  an  immense  quantity — sufficient  to 
cause  death  in  a  few  minutes,  the  blood  piling  up  in  large  heaps 
between  the  nates  and  thighs,  in  some  cases  of  fatal  hemorrhage  in 
typhoid  fever. 

Diagnosis. — The  diagnosis  is  not  difficult,  the  patieut  usually 
finding  that  ha  is  bleeding  from  the  anus  before  other  attention  is 
called  to  it,  unless  it  be  in  inflammatory  conditions  of  the  bowel, 
where  the  nurse  and  physician  are  expecting  and  dreading  it.  The 
location  of  the  hemorrhage  may  be  pretty  definitely  ascertained  by 
examination  of  the  blood  as  soon  as  it  is  voided,  by  the  general  his- 
tory of  the  case,  and  by  considering  the  physical  signs  referable  to 
the  abdomen.  When  the  blood  is  bright  red  in  color  when  voided, 
careful  examination  of  the  rectum — under  chloroform  if  necessary — 
should  be  made  to  determine  whether  or  not  the  seat  of  hemorrhage 
is  within  reach  of  local  treatment. 

Profuse  hemorrhage  during  the  advanced  stage  of  acute  infec- 
tious fevers,  such  as  typhoid,  yellow  and  malarial  fevers,  is  an 
unfavorable  symptom,  though  capillary  hemorrhage  is  far  less  seri- 
ous in  nature  than  arterial.  General  enfeeblement  of  the  constitu- 
tional powers  is  an  unfavorable  condition  for  hemorrhage  to  occur 
in,  fatal  results  being  much  more  liable  to  follow  than  in  the  robust. 
A  single  large  hemorrhage  may  prove  fatal,  as  also  may  many  slight 
ones. 

Treatment. — The  treatment  will  vary,  different  conditions 
demanding  appropriate  measures.  Acute  inflammatory  conditions, 
attended  by  destruction  of  the  mucous  membrane,  will  demand  a 
special  class  of  remedies.  For  instance,  the  hemorrhage  of  acute 
enteritis  will  be  amenable  to  ipecac,  colocynth,  aconite  and  echinaeea, 
in  minute  doses  frequently  repeated,  or  rlius  aromatica  (specific  medi- 
cine gtt.  x-xx).  That  of  dysentery,  when  the  symptoms  are  acute, 
may  be  benefited  by  similar  treatment.  Ulcerative  action  in  the 
large  intestine  attended  by  hemorrhage  may  be  treated  with  minute 


DISEASES  OF  THE  INTESTINES.  443 

doses  of  mercurius  dulcis,  though  profuse  enterorrhaghia  may  call 
for  more  active  astringents,  such  as  a  decoction  of  the  fresh  erigeron 
plant  taken  freely,  or  ten-drop  doses  of  the  oil  on  sugar,  or  ergot  in 
appropriate  doses.  Tannic  and  gallic  acid,  in  two-  or  three-grain 
doses  repeated  every  hour,  assist  materially  in  arresting  pro/use 
hemorrhage  from  the  bowels.  Sometimes  the  lesion  is  in  the  rec- 
tum, where  the  injection  of  the  bleeding  point  with  a  hemostatic 
(1-4  carbolized  oil)  through  a  hypodermic  syringe  will  arrest  the 
hemorrhage  at  once,  when  internal  remedies  may  prove  of  little  avail. 
When  there  is  persistent  dribbling  from  capillary  hemorrhoids, 
they  should  be  systematically  treated  with  interstitial  injections  of 
diluted  carbolic  acid  (1-4  of  olive  oil  and  glycerine,  aa.).  In  urgent 
cases  of  rectal  hemorrhage  euemata  of  a  saturated  solution  of  alum 
may  be  retained  for  their  astringent  effect  until  permanent  measures 
succeed.  Tamponage  may  sometimes  be  resorted  to,  and  scorbutic 
conditions  should  be  properly  met. 

Absolute  rest  in  bed  is  as  important  as  medicine,  tho  recumbent 
position  being  strenuously  insisted  upon — all  evacuations  being 
attended  to  without  assuming  the  upright  position — and  even  turn- 
ing in  bed  should  be  restricted.  It  may  sometimes,  in  non-inflam- 
matory conditions,  be  advisable  to  restrict  peristalsis  with  opiates, 
though  general  adherence  to  this  usage  is  objectionable. 

The  diet  should  be  liquid  and  nutritious,  and  it  should  be  admin- 
istered frequently  and  in  small  quantities.  Cold  applications  favor 
arrest  of  hemorrhage,  and  cold  drinks  and  fluid  foods  are  better  than 
warm.  In  extreme  cases  ice-bags  may  be  placed  upon  the  abdomen 
for  a  limited  time. 

TYPHLITIS. 

Definition. — Inflammation  of  the  caecum.  The  terms  perityph- 
litis  and  paratypTilitis  are  employed  to  designate,  respectively,  in- 
flammation of  the  peritoneal  covering  of  the  caecum  (perityphlitis) 
and  inflammation  of  the  connective  tissue  surrounding  it  (paratyph- 
litis).  As  these  conditions  are,  however,  usually  complications  of 
appendicitis  they  are  not  employed  by  the  best  authors  as  desigua- 
tive  of  separate  diseases.  Inflammation  of  the  caecum  may  arise  as 
a  complication  of  appendicitis,  but  the  term  is  here  used  to  designate 
inflammation  of  the  part,  independent  from  appendical  trouble. 

Etiology. — Inpaction  of  freces  is  the  common  cause  of  typhlitis, 
the  term  '-typhlitis  stercoralis"  often  being  used  to  designate  the 
condition.  Errors  in  diet  are  probably  the  exciting  cause,  though 
repeated  attacks  may  be  diie  to  colds  following  an  established  irrita- 
tion. The  disease  is  most  common  among  young  persons,  boys 


444  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

being  more  frequently  affected  than  girls.  It  is  always  associated 
with  constipation. 

Pathology. — The  anatomical  condition  has  not  been  determined, 
as  few  if  any  fatal  cases  occur. 

Symptoms. — Pain  in  the  right  iliac  fossa,  with  enlargement, 
the  prominence  taking  the  form  of  a  sausage-shaped  tumor,  loss  of 
appetite  and  sometimes  nausea  and  vomiting,  are  the  principal  symp- 
toms. There  is  usually  little  if  any  fever,  though  the  temperature 
may  be  elevated  one  or  two  degrees.  The  pain  and  fullness  may  be 
accompanied  by  tenderness  on  pressure,  and  there  is  usually  dullness 
on  percussion.  The  patient  lies  upon  the  back,  and  may  flex  the 
right  thigh  to  relieve  tension  of  the  abdominal  muscles  in  the  affected 
region.  The  symptoms  are  all  mild,  and  gradually  subside  within 
three  or  four  days  or  a  week. 

Diagnosis. — The  diagnosis  between  this  disease  and  mild  cases 
of  catarrhal  appendicitis  is  rather  difficult,  though  the  sausage-shaped 
tumor  is  regarded  by  some  as  a  diagnostic  feature  of  typhlitis. 
Others,  however,  assert  that  this  symptom  occurs  as  a  secondary 
feature  of  appendicitis. 

Treatment. — Nausea  and  vomiting  may  be  controlled  by 
minute  doses  of  aconite  and  rkus  fox.,  and  potassium  chloride  3x  may 
be  administered  as  a  safeguard  against  plastic  exudation.  Cold  appli- 
cations may  be  used  over  the  affected  part,  though  if  these  are  un- 
pleasant they  may  be  dispensed  with,  warm  or  hot  applications  being 
carefully  avoided.  Rectal  injections  of  tepid  salt  water  may  be  em- 
ployed to  assist  normal  evacuation  and,  in  stubborn  cases,  the  salt- 
water electrode  with  galvanism  may  be  used  in  the  lower  bowel.  The 
diet  should  be  liquid  in  form  and  sparing  in  quantity,  and  the  patient 
should  be  kept  quiet  in  bed  until  a  regular  condition  of  the  bowels 
has  been  established  and  the  pain  and  fullness  have  subsided. 

APPENDICITIS. 

Definition. — Inflammation  of  the  appendix  vermiformis. 

Etiology. — Appendicitis  is  most  liable  to  arise  in  those  of  early 
adult  life,  though  it  may  occur  in  childhood,  even  in  rare  cases  dur- 
ing infancy,  while  it  is  exceedingly  uncommon  in  advanced  age.  It 
has  been  estimated  by  some  writers  that  sixty  per  cent  of  all  cases 
occur  between  the  ages  of  sixteen  and  thirty.  Both  sexes  are  liable 
to  it,  statisticians  differing  as  to  which  is  most  frequently  affected. 
Foreign  bodies,  such  as  grape-seeds,  orange-pits  and  other  foreign 
bodies,  are  probably  often  causal  factors.  Some  peculiarity  of  shape 
or  position  possibly  contributes  to  the  irritation  produced  by  such 
agents  after  lodgment  there,  but  where  the  condition  of  the  part  is 


DISEASES  OF  THE  INTESTINES.  445 

normal  and  there  is  present  no  microbic  element  of  disease,  the  mere 
presence  of  foreign  bodies  cannot  be  considered  an  inevitable  pre- 
cursor. Irritation,  amounting  to  abrasion,  in  such  cases,  may  afford 
entrance  of  microbes  into  the  capillaries  of  the  appendix  to  arouse 
inflammatory  action — in  which  case  foreign  bodies  would  certainly 
be  predisposing  causes.  Adhesions  of  the  appendix  to  adjacent  vis- 
cera might  result  in  teasing  tension,  which  would  finally  excite 
inflammatory  action.  Many  cases  arise  suddenly  after  the  lifting  of 
heavy  weights,  and  such  appendicitis  is  probably  thus  brought  about. 
Over-eating  is  liable  to  be  a  provoking  cause,  especially  when  im- 
proper food  is  taken,  this  being  a  frequent  cause  of  the  recurrence 
of  the  disease  after  recovery  from  a  first  attack.  Irritation  of  the 
caecal  extremity  of  the  appendix  may  result  in  gradual  closure  of  the 
opening  until  complete  obliteration  occurs,  a  hermetically  sealed  cavity 
remaining  in  the  appendix,  which  may  contain  elements  of  fermentation 
or  suppuration. 

Pathology.  —  Two  forms  of  acute  appendicitis  are  '  recognized, 
namely,  catarrhal  and  suppurative. 

In  catarrhal  appendicitis  the  mucous  membrane  is  thickened  and 
engorged,  and  covered  with  a  coating  of  tenacious  mucus,  while  the 

cavity  contains  serum  and  one  or  more 
masses  of  hardened  fecal  concretion,  and 
is  usually  narrowed  in  its  lumen,  espe- 
cially at  its  caecal  extremity.  The  entire 
organ  is  enlarged,  rigid  and  club-shaped, 
with  its  outer  extremity  expanded,  and  the 
peritoneal  covering  is  congested  or  coated 
with  fibrinous  material  and  adherent  to 
adjacent  peritoneal  surfaces.  When  slit 
APPENDICITIS.  longitudinally  the  mucous  membrane  rolls 

b,  iieum.  outward   and   the   peritoneal   covering   in- 

ward,   a    position     afterward    persistently 
maintained  when  not  interfered  with. 

Suppiirative  appendicitis  is  marked  by  the  presence  of  serum  and 
pus  in  the  walls  of  the  appendix  and  upon  its  outer  surface.  When 
the  suppurative  action  is  not  rapidly  destructive,  the  neighboring 
peritoneum  becomes  inflamed  and  covered  with  adhesive  fibrino-pur- 
ulent  material,  which  binds  the  folds  together  in  the  form  of  a  sur- 
rounding wall,  and  incloses  a  cavity  that  becomes  distended  with  pus. 
Burrowing  may  now  occur  and,  if  the  cavity  be  not  drained  by  proper 
surgical  procedures,  purulent  material  may  infiltrate  the  connective 
tissue  of  the  mesentery  and  invade  the  retroperitoneal  tissues,  the 
pus  then  descending  along  the  psoas  or  iliac  fascia  and,  appearing 
externally  below  Poupart's  ligament  as  an  external  abscess,  burrow 


446  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

to  the  peri-nephritic  structure,  or  descend  into  the  pelvis  and  involve 
the  peri-rectal  tissue.  In  rare  cases  the  pus  may  penetrate  the 
obturator  membrane,  pass  through  the  obturator  foramen  and  appinr 
as  a  gluteal  abscess.  In  most  cases  the  abpcess  is  likely  to  burst 
into  the  peritoneal  cavity  and  cause  general  peritoneal  septicaemia; 
or,  without  actual  rupture,  diffuse  suppurative  peritonitis  may  occur. 
The  pus  may  be  profuse  or  limited  in  quantity,  and  when  the  amount 
is  small  it  may  be  circumscribed,  and  if  surrounded  by  a  large 
amount  of  inflammatory  tissue  may  remain  localized,  to  undergo 
absorption  or  other  change.  When  the  amount  is  very  small  absorp- 
tion is  possible,  though  rare. 

In  other  cases  there  is  such  rapid  and  extensive  suppuration  that 
sloughing  of  the  appendix  occurs,  and  its  necrotic  (gangrenous)  frag- 
ments, along  with  the  contents  of  the  cavity,  are  discharged  into  the 
peritoneal  cavity  before  a  limiting  abscess- wall  is  formed,  and  a  vir- 
ulent peritoneal  sepsis  is  set  up,  which  rapidly  ends  the  scene. 

Symptoms.  --  The  symptoms  vary,  according  to  the  gravity  of 
the  pathological  condition.  Where  catarrhal  appendicitis  is  not 
severe  there  is  constipation,  pain  and  tenderness  in  the  region  of 
the  caecum,  nausea  and  loss  of  appetite,  and  where  the  inflammation 
is  somewhat  pronounced  there  is  more  or  less  induration  of  the 
abdominal  tissues  about  the  caBcal  region.  Sometimes  the  symptoms 
are  so  slight  that  the  earlier  stages  pass  unnoticed,  there  being  merely 
slight  local  pain  and  tenderness  in  the  right  iliac  region,  In  most 
cases,  however,  there  is  an  initiatory  chill,  followed  by  vomiting  and 
fever.  Severe  pain  usually  begins  in  the  right  iliac  fossa,  either 
steady  or  of  paroxysmal  character,  and  marked  tenderness  under 
pressure  is  found  at  some  localized  point  in  the  iliac  region,  often  at 
McBurney's  point,  situated  on  a  line  with  the  umbilicus  about  an 
inch  and  a  half  or  two  inches  from  the  right  anterior  spine  of  the 
ilium.  The  temperature  varies  from  101°  to  103°  F.,  and  continues 
elevated  for  three  or  four  days  when,  in  favorable  cases,  it  slowly 
declines,  the  indurati>  n  gradually  passing  away,  the  bowels  moving 
spontaneously  and  the  pain  and  tenderness  disappearing.  In  severer 
cases  the  pain  becomes  more  marked,  sharp  and  diffused,  announcing 
involvement  of  the  peritoneum.  The  right  thigh  is  drawn  up  to 
relieve  the  abdominal  muscles  of  that  side  from  tension,  and  in  walk- 
ing the  patient  bends  forward,  the  erect  posture  causing  pain.  The 
pain  may  now  be  radiated,  extending  over  a  large  portion  of  the 
abdomen  and  involving  the  bladder,  testes,  rectum  and  other  viscera. 
Retention  of  the  urine  may  occur.  The  tongue  becomes  furred,  and 
diarrhoea  may  set  in,  especially  in  children.  As  unfavorable  condi- 
tions progress  the  tongue  becomes  dry  and  brown,  sordes  appear  on 
the  lips  and  teeth,  and  symptoms  of  exhaustion  supervene.  SOUK- 


DISEASES  OF  THE  INTESTINES.  447 

times,  when  the  appendix  turns  backward,  it  is  difficult  to  detect  a 
tumor  in  the  iliac  region,  a  vaginal  or  rectal  examination  enabling 
the  practitioner  to  detect  the  affected  point  deep  in  the  abdomen. 
Where  a  large  amount  of  pus  accumulates  within  the  limiting 
abscess-wall  the  abdominal  tumefaction  may  be  a  marked  feature  of 
the  case  the  abdomen  in  the  region  of  the  caecum  being  enormously 
distended. 

The  position  of  the  appendix  will  determine,  to  considerable 
extent,  the  local  symptoms  and  conditions.  When  it  is  turned  back- 
ward, as  is  often  the  case,  post-  peritoneal  abscess  is  very  liable  to 
follow  suppurative  action,  and  enlargement  of  the  csecal  region  is  not 
likely  to  be  noticed.  In  gangrenous  appendicitis  the  symptoms  are 
abrupt  and  severe  from  the  start.  There  is  a  chill  followed  by  fever, 
with  excruciating  abdominal  pain  marking  the  rapid  spread  of  peri- 
toneal inflammation,  prolonged  vomiting  of  watery  fluids,  rapid,  flut- 
tering pulse,  and  delirium  followed  by  coma. 

Diagnosis. — When  persistent  pain  in  the  caecal  region  attended 
by  elevation  of  temperature  and  constipation  occurs  in  patients  under 
thirty  years  of  age,  with  tumefaction  of  the  part  and  pain  at  McBur- 
ney's  point,  there  is  little  danger  of  confounding  appendicitis  with 
any  other  affection  except  typhlitis;  and  here  an  error  of  diagnosis 
would  not  be  serious  if  radical  surgical  measures  were  not  attempted 
too  early.  The  presence  of  vomiting  would  add  to  the  probability 
of  appendicitis,  and  the  absence  of  tumor  would  not  militate  against 
it  if  other  symptoms  were  marked.  When  an  enlargement  in  the 
iliac  region  with  dullness  on  percussion  pointed  to  purulent  accumu- 
lation, an  aseptic  hypodermic  needle  might  be  used  to  decide  the 
question,  though  due  caution  as  to  sepsis  and  repeated  puncture 
should  attend  such  a  procedure.  Great  haste  to  decide  the  question 
is  not  necessary,  unless  the  case  be  one  of  gangrenous  appendicitis, 
and  here  it  is  doubtful  whether  a  diagnosis  could  be  made  sufficiently 
early  to  afford  substantial  relief  by  operation. 

Prognosis. — The  prognosis  of  acute  catarrhal  appendicitis  is 
favorable  as  to  present  recovery,  though  remaining  adhesions  are  lia- 
ble to  perpetuate  the  difficulty  and  induce  frequent  subcequeut 
attacks.  Under  skillful  surgical  treatment  many  cases  of  suppnrativo 
appendicitis  otherwise  necessarily  fatal  recover,  though  the  ^rryvity 
of  the  disease  is  not  to  be  underestimated.  When  the  peritonaeum 
is  widely  involved  the  chances  of  recovery  are  very  much  lessened, 
and  exhaustive  suppuration  and  final  demise  are  liable  to  succeed  bur- 
rowing abscesses  when  the  post-peritoneal  structures  are  invaded. 
Perforation  of  the  intestine  may  be  followed  by  recovery,  and  the 
pus  may  find  an  external  opening  in  front,  and  the  patient  recover 
without  surgical  aid.  However,  since  the  disease  has  received  special 


448  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

attention  from  a  surgical  standpoint  and  prompt  measures  for  an 
early  evacuation  of  the  pus  have  been  adopted,  it  has  become  much 
less  formidable  than  before. 

Treatment. — While  appendicitis  is  a  disease  in  which  a  knowl- 
edge of  surgery  is  an  important  requirement  for  its  successful  man- 
agement, the  physician  is  also  capable  of  bringing  important  aid  to 
bear,  often  rendering  surgical  aid  unnecessary.  In  recent  times, 
thanks  to  Schiissler,  we  possess  a  remedy  which  exerts  a  potent  influ- 
ence against  the  deposition  of  fibrinous  plastic  material,  and  with  it 
we  may  be  able  to  avert  the  pernicious  adhesions  remaining  after 
ordinary  cases  of  catarrhal  appendicitis,  as  well  as  even  prevent  sup- 
puration, if  the  purulent  form  be  at  hand.  Limited  experience  with 
potassium  chloride  3x  has  suggested  to  me  the  probability  that  a  large 
number  of  surgical  cases  may  be  aborted  before  they  become  marked, 
and  otherwise  portentous  states  brought  to  a  successful  termination 
by  the  early  and  faithful  exhibition  of  this  remedy.  In  all  cases  it 
is  a  perfectly  safe  one  to  say  the  worst  of  it,  and  its  power  to  accom- 
plish good  is  remarkable.  In  several  cases  of  the  kind  I  have  seen 
the  abdominal  tumefaction,  obstinate  constipation,  cffical  pain  and 
elevated  temperature  gradually  subside  under  its  influence  when,  in 
the  opinion  of  old  and  experienced  surgeons,  an  operation  was  urg- 
ently demanded.  It  is  perfectly  safe  to  depend  upon  when  there  is 
appreciable  (even  though  slow)  improvement  of  all  the  symptoms. 
Three  to  five  grains  of  potassium  chloride  3x  should  be  added  to 
four  ounces  of  water,  a  teaspoonful  of  the  mixture  to  be  ordered 
every  hour.  When  this  is  begun  early,  and  the  symptoms  continue 
to  increase  in  severity  for  two  or  three  days,  the  probabilities  are  that 
the  disease  is  beyond  its  control,  though  it  can  do  no  harm  to  con- 
tinue it  until  operative  procedures  are  adopted,  as  no  other  remedy 
promises  so  much,  and  it  must  somewhat  lessen  the  amount  of 
destructive  action. 

In  the  meantime  the  patient  should  remain  quietly  in  bed  and  the 
diet  should  be  limited  to  liquid  food,  administered  sparingly.  Cathar- 
tics should  under  no  circumstances  be  allowed,  but  daily  efforts  to 
evacuate  the  bowels  with  warm  and  soothing  enemata  should  be 
made.  Hot  applications  are  to  be  avoided,  and  very  cold  ones  are 
not  commendable.  Opiates  may  be  allowed  in  moderate  doses, 
though  the  patient  is  better  off  without  them  if  the  pain  is  bearable. 
If  febrile  action  is  marked  properly  selected  sedatives  should  be 
administered  in  small  doses,  and  where  there  is  prominent  sugges- 
tion of  gangrenous  tendency  echinacea  should  constitute  an  important 
feature  of  the  medication.  If  the  pain  and  tumefaction  increase,  in 
spite  of  medical  measures,  surgical  aid  should  be  invoked  early,  and 


DISEASES  OF  THE  INTESTINES.  449 

this  should  constitute  the  first  resource  in  gangrenous  Appendicitis, 
which  may  prove  fatal  in  a  few  hours  without. 

PROCTITIS. 

Synonym. — Rectitis. 

Definition, — A  catarrhal  inflammation  of  the  rectum,  due  to 
local  exciting  causes,  differing  from  that  attending  dysentery  by  the 
absence  of  constitutional  symptoms. 

Etiology. — Sometimes  indigestible  substances,  such  as  fish 
bones,  particles  of  skewer,  etc.,  may  be  accidentally  swallowed  with 
the  food  and  pass  through  tlio  alimentary  canal,  to  become  lodged  in 
the  rectum,  to  there  excite  inflammatory  action.  This  is  not  an  un- 
common occurrence  when  persons  who  are  intoxicated  partake  of 
food  containing  such  debris.  Several  cases  of  the  kind  have  occurred 
in  my  experience,  and  occasionally  an  instance  has  been  followed  by 
severe  inflammation,  resulting  in  deep-seated  abscess  in  the  part. 
Other  foreign  substances,  such  as  particles  of  apple-core,  berry- 
seeds,  plum-pits,  etc.,  mc.y  also  result  in  such  irritation.  Hardened 
faeces,  hemorrhoids,  sitting  long  on  very  cold  substances  and  other 
exciting  causes  may  be  named. 

Symptoms. — Tenesmuc  is  the  first  symptom,  and  frequently  it 
is  the  prominent  one  throughout.  Sometimes  there  are  evacuations 
of  bloody  mucus  attended  by  straining  at  stool,  burning  in  the  part 
and  shooting  pains  in  the  back  and  loins,  or  into  the  lower  extremi- 
ties. A  persistent  sensation  as  of  a  foreign  body  in  the  rectum  gives 
rise  to  repeated  efforts  at  evacuation,  and  anal  prolapsus  is  very  lia- 
ble to  finally  result.  Hemorrhoids,  strangury,  headache  and  other 
constitutional  symptoms  and  even  chronic  rectitis  may  finally  attend. 
Hardened  faeces  sometimes  play  an  important  part  in  this  affection, 
the  rectum  becoming  impacted  with  a  hard  mass,  which  is  too  large 
to  pass  the  anal  outlet,  and  the  colon  may  become  filled  withsterco- 
raceous  material  which  may  be  traced  along  the  course  of  the  large 
intestine  by  irregular  masses  felt  externally. 

Chronic  rectitis  is  attended  by  the  daily  discharge  of  mucus,  pus 
and  sanious  material,  with  more  or  less  tenesmus.  Erosion  and 
induration  of  the  rectal  mucous  membrane  exists,  and  the  finger 
detects  a  hardened,  rigid  condition  upon  digital  examination.  Con- 
stipation attends,  the  fecal  material  voided  being  hardened  and 
impacted. 

Diagnosis. — In  proctitis  from  local  causes  there  is  no  fever, 
while  in  that  which  arises  in  dysentery  the  thermometer  shows  an 
elevation  of  three  or  four  degrees.  The  pain  of  proctitis  is  also  dif- 
ferent in  character,  it  usually  being  confined  to  the  region  of  the 

30 


460  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

rectum  or  radiating  to  the  back  or  loins,  while  that  of  dysentery 
usually  lingers  along  the  course  of  the  colon  and  is  frequently  near 
the  umbilicus  and  paroxysmal,  corresponding  to  the  periods  of  evac- 
uation. An  inspection  of  the  rectum  will  decide  whether  the  symp- 
toms arise  from  hemorrhoids,  and  rectal  cancer  comes  on  so  slowly 
that  it  cannot  be  mistaken  for  proctitis,  while  the  presence  of  the 
characteristic  cachexia  precedes  extreme  local  irritation. 

Prognosis. — The  prognosis  is  good  when  the  disease  is  prop- 
erly managed.  If  the  exciting  cause  be  some  hard  and  irritating 
substance  and  its  removal  be  neglected,  deep-seated  abscess,  fistula 
or  chronic  proctitis  may  result.  Erosions  left  behind  may  give  rise 
to  chronic  rectal  catarrh  or  rectal  stricture. 

Treatment. — The  first  important  step  is  to  decide  whether  there 
be  any  foreign  body  present  which  may  be  causing  the  difficulty.  If 
so  it  should  be  carefully  removed  at  once,  and  treatment  afterward 
instituted  to  control  the  remaining  inflammation.  In  such  cases  the 
finger  will  be  the  most  reliable  and  least  objectionable  exploring 
agent,  and  also  the  best  means  by  which  to  remove  offending  sub- 
stances without  injury  to  the  part.  Small  doses  of  aconite  and  rhus 
tox.t  combined  with  collinsonia,  will  assist  in  controlling  the  local 
inflammation.  R  Lloyd's  or  Worden's  aconite  gtt.  v-vii,  green-plant 
tincture  rhus  tox.  gtt.  x-xv,  specific  collinsonia  gtt.  x,  water  f iv.  M., 
and  order  a  teaspoonful  every  hour.  Locally,  the  following  may  be 
used  as  an  enema,  to  be  retained  until  absorbed  and  repeated  every 
hour  or  two,  according  to  the  urgency  of  the  case:  R  Echafolta  ^i, 
water  fii.  Mix.  The  patient  should  remain  quiet  in  bed  and  be 
allowed  only  a  liquid  diet  for  several  days.  In  chronic  proctitis  the 
enema  of  echafolta  should  be  employed  three  or  four  times  a  day, 
and  collinsonia  and  echofalta  should  be  administered  internally  three 
or  four  times  daily  in  appropriate  doses.  Berberis  aquifolium  con- 
tinued for  a  long  time,  in  connection  with  collinsonia  or  negundium, 
will  be  of  considerable  service  as  an  internal  agent. 

PERIPROCTITIS. 

Definition. — Periproctitis  is  an  inflammation — usually  suppu- 
rative — of  the  connective  tissue  surrounding  the  rectum. 

Etiology. — The  inflammation  may  be  coextensive  with  that  of 
proctitis  or  of  other  diseases  which  may  affect  the  rectal  mucous 
membrane,  such  as  cancer,  ulceration,  etc.  It  occasionally  occurs  as 
a  result  of  tubercular  infection  of  the  part,  or  of  pyaemic  metastasis. 
Traumatism  is  its  most  common  cause,  the  lodgement  and  neglect 
of  some  foreign  body  in  the  rectum,  or  blows  near  the  anus  being 
very  liable  to  result  in  such  a  condition. 


DISEASES  OF  THE  INTESTINES.  451 

Pathology. — Suppurative  inflammation  of  the  connective  tissue 
occurs  at  some  localized  point,  and  fluctuation  may  by  felt  through 
the  rectal  wall  as  the  destructive  action  progresses,  the  soft  part 
bulging  into  the  rectum.  The  pus  may  burrow  in  the  vaginal  or  vesi- 
cal  wall  and  establish  fistulae,  or  a  track  of  suppuration  may  form 
completely  around  the  rectum.  In  other  instances  the  abscess  may 
open  into  the  rectum  and  a  permanent  suppurating  sinus  become 
established.  Proliferation  of  new  connective  tissue  may  result  in 
stricture  of  the  rectum,  or  proliferating  epithelial  elements  may 
line  the  abnormal  cavities  with  mucous  membrane  similar  to  that 
of  the  rectum. 

Symptoms. — Severe  pain  of  throbbing,  burning  or  tensive  char- 
acter, attended  by  a  sense  of  fullness  in  the  rectum,  is  the  prominent 
symptom.  If  the  inflammation  involve  structures  near  the  anus,  a 
reddened  prominence,  of  fluctuating,  sensitive  character  soon  devel- 
ops. Nausea  and  vomiting  may  attend  severe  cases.  An  exami- 
nation of  the  affected  part  will  discover  the  local  signs  of  abscess, 
the  finger  detecting  a  fluctuating  tumor,  sensitive  to  the  touch, 
extending  into  the  rectum.  Upon  rupture  the  contents  of  the 
abscess  are  extremely  offensive  in  odor,  and  they  may  be  mixed  with 
faecal  material. 

Treatment. — The  most  important  object  is  to  insure  evacuation 
of  the  abscess,  not  into  the  rectum  but  through  the  true  skin,  near 
the  anus.  This  demands  proper  surgical  acumen.  If  treatment  is 
begun  early  there  may  be  a  possibility  of  avoiding  the  abscess,  espe- 
cially if  it  be  of  traumatic  origin  and  the  provoking  cause  has  been 
removed  in  the  start.  For  this  purpose  potassium  chloride  3x  may  be 
administered  in  the  usual  manner.  The  special  sedatives,  especially 
aconite  and  rhus  fox.,  are  excellent  to  control  serious  constitutional 
symptoms,  and  if  septic  conditions  arise  baptisia  and  echinacca  should 
not  be  forgotten.  If  chronic  purulency,  too  high  for  the  pus-pockets 
to  be  reached  from  below  exist,  the  persistent  use  of  the  salt-water 
galvanic  electrode  promises  much,  if  begun  at  an  early  date  and 
faithfully  used  for  several  mouths  three  or  four  times  a  week. 
In  such  cases  the  general  condition  of  ths  patient  should  not  be  neg- 
lected, appropriate  adjuvant  treatment  being  employed  as  demanded. 
Calcium  sulphide,  berberis  aquifolium  or  other  antisuppurative  may  be 
needed  to  bring  prolonged  suppuration  to  a  close. 

HEMORRHOIDS. 

Synonym. — Piles. 

Definition. — A  disease  characterized  by  the  formation  of  vascu- 


452  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

lar  tumors  in  the  lower  rectum  and  about  the  anus,  from  varicosities 
of  the  hemorrhoidal  veins  with  subsequent  inflammatory  change. 

Etiology. — Straining  at  stool  often  causes  rupture  of  one  or 
more  of  the  coats  of  the  hemorrhoidal  veins,  and  this  may  b^  fol- 
lowed by  permanent  hemorrhoidal  tumors  at  the  points  of  greatest 
dilatation.  Biding  over  rough  roads  or  sitting  on  cold  seats  for  a 
long  time  may  cause  it  by  inducing  congestion.  Pregnancy  is  often 
attended  by  hemorrhoids  due  to  pressure  on  the  pelvic  veins,  and 
parturition  may  be  attended  by  such  forcible  straining  as  to  result 
in  a  permanent  hemorrhoidal  condition.  Constipation  is  a  common 
cause,  both  the  straining  during  defecation  and  faecal  pressure  upon 
the  hemorrhoidal  veins  tending  to  such  result.  It  is  most  common 
in  persons  beyond  middle  life,  though  younger  ones  are  not  exempt 
when  exposed  to  exciting  causes.  It  is  more  common  in  single 
women — those  who  have  not  borne  children — after  the  menopause, 
this  period  frequently  being  immediately  followed  by  the  appearance 
of  hemorrhoids.  Obstruction  of  the  portal  circulation  from  such  dis- 
eases of  the  liver  as  cirrhosis,  atrophy  or  passive  hyperaemia,  is 
almost  certain  to  eventuate  in  hemorrhoids;  and  influences  which 
cause  engorgement  of  the  vena  cava,  such  as  cardiac  or  pulmonary 
obstruction,  are  very  liable  to  be  followed  by  it.  The  abuse  of 
drastic  cathartics  is  often  provocative  of  piles,  large  doses  of  colo- 
cynth,  aloes,  etc.,  frequently  bringing  on  the  disease. 

Pathology, — Acute  hemorrhoids  may  be  nothing  more  than 
dilated,  inflamed  veins,  sometimes  containing  thrombi  of  coagulated 
blood.  As  they  continue  without  proper  treatment,  however,  they 
may  gradually  become  surrounded  by  bloodvessels,  and  the  vasa 
vasorum,  from  inflammatory  action,  may  become  hypertrophied,  until 
the  tumors  consist  of  aggregations  of  dilated  bloodvessels  with  firm 
fibrous  coats,  constituting  permanent  and  more  or  less  firm  enlarge- 
ments which,  however,  increase  or  diminish  in  size  as  their  vascular- 
ity  fluctuates. 

Various  divisions  of  hemorrhoids  have  been  made.  Those  which 
arise  within  the  sphincter  ani  and  which  can  be  returned  to  the  rec- 
tum, to  remain  there,  if  prolapsed,  are  termed  internal  hemorrhoids ; 
while  those  which  arise  without  the  sphincter  ani  and  cannot  be  car- 
ried up,  or  which  immediately  return  when  lifted  above  the  sphinc- 
ter, are  termed  external  hemorrhoids.  External  hemorrhoids  commonly 
occur  just  at  the  verge  of  the  anus,  upon  the  mucous  membrane. 
Sometimes  straining  at  stool  is  followed  by  rupture  of  one  of  the 
external  hemorrhoidal  veins  with  the  formation  of  a  blood-clot 
within  the  point  of  rupture  which,  if  not  soon  evacuated,  is  after- 
ward absorbed,  the  dilated  sack  afterward  becoming  shriveled  and 
remaining  as  a  wrinkled  tab  of  muco-cutaneous  tissue.  Internal 


DISEASES  OF  THE  INTESTINES.  453 

hemorrhoids  are  sometimes  dark  blue,  livid  and  non-fluctuating, 
more  rarely  bright  red  and  pulsating,  suggesting  the  presence  of 
one  or  more  arterioles,  and,  when  punctured,  project  a  stream  of 
bright  red  blood  in  jets.  Internal  hemorrhoids,  then,  may  be  either 
venous  or  arterial.  Another  form  of  internal  hemorrhoids  consists 
of  flat  mucous  surfaces  covered  by  bright  red  capillary  loops  (capil- 
lary hemorrhoids),  which  bleed  easily  and  frequently,  the  amount  of 
blood,  though  small  in  quantity  in  a  given  time,  constituting  finally  a 
serious  loss  to  the  system.  The  hemorrhage  which  occurs  in  hemor- 
rhoids almost  universally  proceeds  from  above  the  sphincter  (inter- 
nal piles)  and  usually  from  capillary  hemorrhoids,  though  the  coat  of 
an  arterial  or  venous  hemorrhoid  may  be  so  attenuated  as  to  give 
way  and  allow  of  considerable  loss  of  blood  in  a  short  time,  at  fre- 
quent intervals.  Rupture  of  venous  internal  hemorrhoids  is  not 
rare,  aud  sufferers  sometimes  rupture  them  with  their  fingers,  believ- 
ing that  it  will  afford  them  temporary  relief  from  pain.  The 
sphincter  ani  is  usually  irritable,  and  when  internal  hemorrhoids  are 
prolapsed,  as  often  occurs  during  defecation,  spasmodic  contraction 
of  the  sphincter  about  them  above  the  protruding  masses  may  cause 
strangulation,  unless  the  prolapsed  tissues  are  replaced.  In  other 
cases,  however,  the  sphincter  may  be  relaxed,  and  chronic  prolapsus 
of  the  hemorrhoids  may  persist. 

Symptoms. — Unless  strangulation  or  severe  inflammation,  with 
septic  absorption  occur,  hemorrhoids  afford  only  local  symptoms. 
There  is  a  sensation  as  of  some  foreign  body  in  the  rectum,  with 
pain  in  different  cases,  of  widely  varying  character.  Sometimes  this 
is  dull  and  aching  with  dragging  sensations  about  the  anus,  some- 
times it  is  sharp  and  piercing  as  though  there  were  a  sharp  instru- 
ment driven  into  the  anus,  and  sometimes  it  is  throbbing  as  though 
an  abscess  were  forming.  In  some  cases  of  internal  piles  the  pain 
is  almost  confined  to  the  lumbar  and  sacral  regions,  and  in  others 
it  may  radiate  to  the  hips  and  lower  extremities.  Most  cases,  if 
not  all,  are  subject  to  periods  of  intense  excerbation,  due  to  cold, 
constipation,  riding  over  rough  roads,  severe  exertion,  etc.,  in 
which  the  patient  suffers  severely,  while  there  are  varying  peri- 
ods in  which  not  much  discomfort  may  be  experienced.  When  the 
disease  becomes  well  advanced  and  there  are  extreme  changes  of 
structure,  the  patient  becomes  a  constant  sufferer,  every  period  of 
defecation  being  one  of  anguish,  prolapse  of  a  mass  of  distended 
tumors  often  attending  the  exit  of  the  stool  and  necessitating  its 
return,  a  performance  at  which  the  sufferer  after  a  time  becomes 
an  adept.  Hemorrhage  is  common  at  these  times,  and,  if  consti- 
pation attend,  the  suffering  is  prolonged  and  intense. 

When    there   is    considerable    hemorrhage  the  patient  becomes 


454  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

anaemic  after  a  time,  and  dyspeptic  symptoms  are  common,  probably 
from  reflex  irritation.  The  bladder  and  urethra  commonly  sympa- 
thise in  severe  cases,  and  urination  may  be  difficult  and  painful. 
Vesical  tenesmus  may  be  almost  a  constant  symptom.  In  females 
vaginal  pain  may  be  due  to  such  cause.  Hemorrhoidal  persons  are 
frequently  melancholy  and  morose.  Constipation  is  the  rule,  though 
many  are  subject  to  diarrhoea. 

Diagnosis. — A  rectal  examination  can  hardly  fail  to  result  in  a 
correct  diagnosis.  The  only  rectal  tumor  liable  to  be  confounded 
with  hemorrhoids  is  a  rectal  polypus,  which  is  colorless,  prediculated 
and  painless.  Venereal  growths  occur  at  the  edge  of  the  anus  but 
are  not  painful,  and  other  symptoms  of  syphilis  usually  observable 
will  aid  in  distinguishing  this  disease  from  hemorrhoidal  tumors, 
which  are  smooth,  tense  and  shiny,  and  usually  purplish  in  color, 
more  or  less  sensitive  to  the  touch  and  commonly  painful.  Hemor- 
rhoids bleed  easily,  while  other  rectal  growths  are  not  liable  to. 
Capillary  hemorrhoids  are  found  within  the  sphincter  and  consist  of 
patches  of  bright  red  capillary  loops,  which  bleed  easily  upon  being 
disturbed. 

Prognosis. — When  hemorrhoids  are  treated  early,  before  in- 
flammatory changes  occur,  there  is  good  prospect  that  specific  con- 
stitutional treatment  may  succeed  in  effecting  a  cure — at  least  that 
the  difficulty  may  be  banished  for  years  before  it  will  again  appear, 
unless  the  patient  is  continually  exposed  to  its  causes.  After 
inflammatory  changes  have  occurred,  radical  surgical  measures  are 
demanded,  and  medicines  by  mouth  can  be  palliative  only.  Capil- 
lary hemorrhoids  demand  radical  treatment  from  the  start,  and 
should  not  be  allowed  to  continue,  as  stubborn  ansemia  may  arise, 
to  continue  for  years  after  the  completion  of  a  cure  of  the  local 
trouble. 

Treatment. — Though  usually  classed  as  a  surgical  disease, 
hemorrhoids  may  often  be  successfully  treated  by  the  physician 
with  internal  remedies.  Collinsonia  specifically  influences  the  tis- 
sues of  the  rectum,  and  many  cases  of  acute  and  subacute  piles  may 
be  permanently  relieved  by  its  internal  administration.  Where  con- 
stipation attends  the  following  prescription  is  an  excellent  one: 
R  Green-plant  tincture  of  collinsonia  ^i-ii,  fluid  extract  cascara  fi, 
simple  elixir  ad  fiv.  Sig.  Teaspoonful  every  three  or  four  hours 
during  the  day.  Where  there  is  profusion  of  venous  piles  below 
the  sphincter — external  hemorrhoids — hamamelis  sometimes  answers 
a  better  purpose,  and  two  or  three  drachms  of  the  distilled  extract 
may  be  substituted  for  the  collinsonia  in  the  prescription  just 
named.  Where  a  local  application  is  essential  to  relieve  pain,  the 
following  may  be  employed :  R  Fluid  extract  belladonna  jii,  oil  of 


DISEASES  OF  THE  INTESTINES.  455 

erigeron  canadense  ^iv,  oleum  olivae  ad  fi.  Sig.  Apply  morning  and 
evening  and  at  times  of  defecation.  In  stubborn  cases  cesculus  hip. 
pocastum  may  be  studied.  Fullness,  dryness  and  sense  of  constric- 
tion, with  aching  pain  and  weakness  in  the  sacro-lumbar  region  is 
the  accepted  picture  for  its  use,  some  asserting  that  it  is  specific, 
when  there  is  absence  of  constipation.  There  are  other  remedies 
but  these  are  the  leading  ones.  When  prolapsus  attends  defecation 
the  use  of  a  copious  injection  of  weak  salt  water  prior  to  the  attempt 
at  evacuation  may  assist  in  preventing  this  accident.  Sometimes 
small  doses  of  the  2x  or  3x  trituration  of  podophy llin  may  be  used  for 
this  condition  (prolapsus). 

Dr.  O.  S.  Laws  (Dynamical  Therapeutics)  recommends  a  new 
remedy — Negundium  Americanum  (box  elder) — above  all  others  for 
specific  action  in  hemorrhoids.  He  uses  ten  or  fifteen  grains  of  the 
powdered  bark  of  the  roots  of  yearling  plants,  or  tablespoonful  or  more 
doses  of  a  decoction  several  times  daily.  "Recent  cases  of  hemor- 
rhoids can  be  completely  cured  in  this  way  and  the  old  hard  ones 
temporarily  relieved."  He  considers  it  far  superior  to  collinsonia 
in  this  place.  Probably  a  saturated  tincture  of  the  bark  could  also 
be  relied  upon,  and  it  would  be  a  more  stable  form.  It  is  hopeful 
that  it  will  be  supplied  to  our  drug  market. 

After  permanent  tumors  of  large  size  become  established  and 
organized,  internal  medication  can  only  modify  unpleasant  symp- 
toms— more  radical  treatment  must  then  be  employed.  The  White- 
head  operation  will  come  into  use  when  the  entire  lower  inch  of  the 
rectum  becomes  a  mass  of  liemorrhoidal  tumors,  though  hypodermic 
injections  of  carbolized  glycerine  and  olive  oil  will  cure  most  cases, 
when  patiently  tried.  The  sphincter  should  be  stretched  to  prevent 
strangulation  of  the  prolapsed  mass  after  a  treatment  of  this  kind, 
though  if  care  be  exercised  this  may  be  avoided  by  putting  the  tumor 
up  after  an  operation,  and  the  divulsion  may  be  allowed  to  go  until 
the  latter  part  of  the  treatment. 

The  diet  should  be  spare  and  devoid  of  indigestible  substances, 
and  so  selected  as  to  encourage  relaxation  of  the  bowels. 

AMYLOID  DEGENERATION  OF  THE  BOWELS. 

THIS  is  a  disease  of  rare  occurrence,  and  when  it  appears  it  is 
usually  secondary  to  phthisis  or  chronic  suppuration,  especially  long- 
standing suppuration  of  bone.  The  degenerative  action  begins  in 
the  terminal  branches  of  the  mesenteric  arteries  and  involves  the 
intestinal  wall  later,  sometimes  affecting  the  entire  thickness  of  the 
part,  and  being  marked  by  ulceration  of  the  mucous  membrane. 


456  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

Both  the  large  and  small  intestine  may  be  involved,  though  the 
lower  portion  of  the  ileum  is  most  susceptible. 

The  symptoms  are  obscure,  there  being  a  painless,  chronic  diar- 
rhoea, without  local  tenderness  or  fever,  with  gradual  loss  of  strength. 
If  there  is  ulceration  of  the  mucous  membrane  there  will  be  blood 
and  pus  in  the  stools,  and  such  symptoms  attended  by  phthisis, 
chronic  suppuration,  or  other  wasting  disease  may  be  interpreted  as 
belonging  to  the  condition  under  consideration.  An  autopsy  will 
usually  disclose  accompanying  amyloid  degeneration  of  the  liver  and 
spleen. 

Nothing  but  palliative  treatment,  on  general  principles,  can  be  sug- 
gested, as  fatal  results  sooner  or  later  follow. 

DlABBH(EA- 

Definition. — The  term  diarrhoea  literally  signifies  "I  flow,"  and 
is  applied  to  a  condition  in  which  there  is  a  frequent  discharge  of 
fluid  or  semi-fluid  faeces,  unattended  by  tenesmus. 

Etiology. — Diarrhoea  may  be  irritative,  symptomatic,  mechan- 
ical, nervous,  choleraic,  vicarious,  critical,  colliquative  or  functional 
in  character.  It  attends  many  diseases  under  one  of  these  guises, 
and  sometimes  exists  as  an  independent  affection  due  to  functional 
disturbance  of  the  alimentary  canal  or  of  the  digestive  processes. 

Irritative  diarrhoea  attends  all  cases  marked  by  inflammatory 
invasion  of  the  intestinal  mucous  membrane,  such  as  the  various 
forms  of  enteritis,  typhoid  fever,  certain  cases  of  mineral  poisoning, 
intestinal  worms,  excessive  biliary  discharges,  drastic  catharsis, 
improper  food,  etc. 

Symptomatic  diarrhoea  may  be  the  result  of  certain  acute  and 
chronic  affections,  such  as  Bright's  disease,  the  exanthemata,  pyaemia, 
leukaemia,  etc. 

Mechanical  diarrhoea  is  the  result  of  obstruction  to  the  portal  cir- 
culation, causing  transudation  of  serum  from  the  bloodvessels  into 
the  intestinal  canal.  This  may  occur  in  hepatic,  cardiac  or  pulmo- 
nary affections. 

Nervous  diarrhoea  may  be  due  to  grief,  great  anxiety,  fright  or 
severe  shock  or  pain.  The  discharges  are  then  largely  serous, 
though  if  the  exciting  cause  appear  soon  after  eating  there  may  be 
evacuation  of  undigested  food  (lienteric  diarrhoea). 

Choleraic  diarrhcea  is  the  term  applied  to  the  watery  evacuations 
which  pass  with  a  gush,  during  cholera,  cholera  morbus  and  chol- 
era infantum. 

Vicarious  diarrhoea  is  the  result  of  sudden  arrest  of  secretion, 
usually  of  the  skin,  the  diarrhoea  being  compensatory.  It  may  fol- 


DISEASES  OF  THE  INTESTINES.  457 

low  sudden  chilling  of  the  surface,  or  may  attend  undue  indulgence 
in  diet  during  hot  summer  weather  In  other  cases,  it  may  be  due 
to  overeating. 

Symptoms. — Under  this  head  several  divisions  of  diarrhoea 
have  been  suggested.  In  simple  fcecal  diarrhoea  the  evacuations  are 
normal  as  to  character,  but  increased  in  quantity  and  fluidity.  In 
bilious  diarrhoea  the  discharges  are  greenish-yellow,  suggesting  an 
abnormal  amount  of  bile,  though  bismuth  or  other  drugs  mav  cause 
similar  appearances,  and  due  allowance  should  be  made  for  medica- 
tion to  which  the  patient  may  have  been  previously  subjected. 
When  the  evacuations  are  largely  water  the  condition  is  termed 
serous  diarrhoea,  while  mucous  and  muco-purulent  evacuations  may 
afford  mucous  diarrhoea.  Fatty  diarrhoea  may  attend  faulty  pancre- 
atic action,  and  crapulous  diarrhoea  may  follow  immediately  upon 
overindulgence  at  the  table.  A  critical  diarrhoea  may  attend  the  crisis 
of  a  disease,  disappearing  after  the  crisis  is  over,  and  a  colliquative 
diarrhoea  (profuse  and  serous)  may  attend  the  close  of  such  wasting 
diseases  as  Bright's  disease,  phthisis,  cancer,  etc. 

Frequent  large  evacuations  mark  an  attack  of  diarrhoea,  though 
the  size  of  the  discharges  diminishes  as  the  disease  continues.  The 
evacuations  are  often  expelled  with  a  gush,  especially  if  the  dis- 
charges be  watery  in  character,  though  in  other  cases  they  may 
not  be  forcible.  Serous  diarrhoea  is  often  attended  by  cramps  in  the 
extremities,  and  colicky  pains  and  the  expulsion  of  flatus  may  occur, 
though  in  some  cases  it  may  be  painless.  Febrile  action  may  attend 
some  cases,  and  thirst,  chilliness  and  anorexia  be  present.  Serous 
diarrhoea  is  usuallv  attended  by  scanty  urinary  secretion,  and  the 
urine  may  be  albuminous  and  highly  acid.  Large  quantities  of  free 
fat  may  be  found  in  the  stools  of  fatty  diarrhoea.  Some  cases  of 
diarrhoea  may  result  beneficially,  though  usually  rapid  prostration 
attends  protracted  cases.  Digestion  and  assimilation  are  interfered 
with,  and  the  patient  loses  flesh  rapidly,  the  skin  becoming  dry  and 
harsh,  and  the  individual  irritable  and  despondent. 

Chronic  diarrhoea  is  dependent  upon  some  structural  disease  of 
the  alimentary  canal,  such  as  chronic  enteritis,  intestinal  ulceration, 
tubercular  or  syphilitic  disease  of  the  intestines,  scurvy,  malaria,  etc. 

Treatment. — The  treatment  of  diarrhoea  will  depend  upon  the 
cause  and  the  condition  of  the  patient  at  the  the  time  of  attack.  If 
the  diarrhoea  depend  upon  the  presence  of  irritating  food  some  uuir- 
ritating  but  active  cathartic,  such  as  the  compound  powder  of  jalap 
and  senna,  may  be  used  to  assist  in  its  removal.  Following  this  a 
soothing  agent,  such  as  kaki,  epilobium,  bismuth,  rhus  aromatica  or 
other  remedy,  should  be  administered,  in  appropriate  doses.  Some- 
times potassium  b^hrom.  3x  will  serve  a  better  purpose.  When 


458  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

serous  diarrhoea  is  present,  two  possibilities  as  to  cause  are  pre- 
sented, namely,  obstruction  to  the  portal  circulation,  and  relaxation 
of  the  intestinal  capillaries.  In  the  first  attention  must  be  paid  to 
the  hepatic,  cardiac  and  pulmonary  circulation,  and  in  the  other  co/> 
illary  astringents,  such  as  erigeron,  cinnamon,  achillea  or  other  agent, 
should  be  employed.  In  bilious  diarrhoea  chelidonium,  bryonia, 
podophyllin  in  minute  doses  and,  in  some  cases,  mercurius  dulcis  3x 
may  be  thought  of.  Oxide  of  zinc  has  been  highly  recommended  in 
nervous  diarrhoea.  Fatty  diarrhoea  is  best  treated  with  olive  oil 
and  a  diet  composed  largely  of  pickled  olives.  A  wineglassful  of 
olive  oil  should  be  taken  three  or  four  times  daily,  and  pickled 
olives  taken  freely  with  each  meal.  Lienteric  diarrhoea  may  require 
the  use  of  ipecac,  aconite,  rhus  tox.  or  other  sedative.  In  all  cases 
fermentation  should  be  prevented  by  the  frequent  use  of  half- 
drachm  doses  of  Marchand's  hydrozone,  diluted  at  the  time  of  admin- 
istration with  two  ounces  of  distilled  or  boiled  water.  Malarial 
diarrhoea  will  call  for  arseniate  of  quiiiia  3x,  quinine  or  other  anti- 
malarial  agent.  A  bland  diet  and  the  recumbent  position  are 
important. 

CONSTIPATION. 

Definition. — Constipation  is  a  term  applied  properly  to  reten- 
tion of  faeces  from  any  cause,  though  here  it  is  intended  to  refer  to 
a  condition  where  the  retention  is  due  to  functional  derangement  of 
the  bowels  and  where  the  obstruction  is  purely  faecal  in  character. 

Etiology. — Habits  and  modes  of  life  often  give  rise  to  habitual 
constipation.  Among  these  may  be  mentioned  sedentary  habits, 
neglect  to  attend  promptly  to  daily  evacuation,  habitual  use  of  opi- 
ates and  alcohol,  sparing  ingestion  of  fluids,  etc.  Hepatic  torpor  may 
be  provocative  of  it,  many  dark  persons  suffering  habitual  constipa- 
tion all  their  lives  from  this  cause.  Certain  chronic  diseases,  as 
neurasthenia,  anaemia,  hysteria  and  structural  derangement  of  the 
brain  and  spinal  cord  may  cause  it.  Uterine  affections  attended  by 
irritation  and  congestion  are  common  causes  of  the  condition  among 
women,  and  prostatic  hypertrophy  among  old  men  frequently  results 
in  it.  Certain  articles  of  diet  may  cause  faecal  impaction  at  first, 
and  if  this  condition  persists  for  a  long  time  a  constipation  habit  is 
finally  established,  through  permanent  perversion  of  the  intestinal 
secretions.  Atony  of  the  bowels  may  be  due  to  long-continued  dis- 
tention,  and  when  this  condition  is  relieved  the  intestinal  torpor  may 
be  so  established  as  to  demand  vigorous  measures  for  its  permanent 
cure.  Diseased  conditions  of  the  mucosa  may  result  in  persistent 
dryness  in  some  portion  of  the  intestinal  canal,  faecal  accumulation 
stubbornly  occurring  there.  Prolonged  mental  labor,  melancholia, 


DISEASES  OF  THE  INTESTINES.  459 

insanity  and  other  disturbances  of  the  brain  are  not  unlikely  to  be 
attended  by  constipation.  However,  by  far  the  most  common  cause 
and  one  which  gives  rise  to  conditions  just  suggested  as  etiological 
factors,  is  orificial  irritation — rectal  pockets,  papillae,  fissures  of  the 
anus,  hemorrhoids,  etc. 

Pathology. — Though  no  lesion  may  appear  at  first,  long  impac- 
tion  of  faeces  may  result  in  dilatation  of  the  intestine,  with  thicken- 
ing of  its  walls.  Pressure  and  irritation  of  hardened  faeces  may  give 
rise  to  ulceration  of  the  mucous  membrane,  and  perforation  some- 
times occurs,  both  from  ulceration  and  increased  peristaltic  action. 
The  dilatation  which  occurs  moot  markedly  about  the  sigmoid  flex- 
ure may  result  in  paralysis  of  the  muscular  coat  of  the  intestine,  and 
pouches  containing  faecal  material  and  mucus  may  form  along  the 
colon.  The  impacted  faeces  sometimes  become  so  hardened  as  to 
resist  the  edge  of  a  knife.  Various  accidental  substances,  such  as 
the  stones  of  various  fruits,  hair,  pebblos,  gall-stones,  etc.,  may  form 
the  nuclei  of  such  impactions,  and  though  not  formidable  enough  to 
cause  obstruction  by  themselves,  they  may  assist  in  the  formation  of 
masses  which  may  resist  all  efforts  at  dislodgment.  Such  diseases 
as  hemorrhoids,  rectal  abscess,  fistula,  etc.,  may  complicate  cases  of 
severe  and  long-continued  constipation,  and  be  the  result,  as  well 
as  the  cause  of  them. 

Symptoms. — The  symptoms  of  constipation  are  so  varied  that 
the  only  one  that  can  be  relied  upon  is  absence  of  regular  faecal  evac- 
uation, without  severe  local  and  constitutional  symptoms.  Subjects 
of  the  disease  are  liable  to  be  dyspeptics,  to  have  headaches,  erratic 
appetites,  insomnia,  and  be  melancholic  and  despondent.  Sympa- 
thetic disturbance  of  the  hepatic  functions,  with  slight  symptoms  of 
jaundice,  is  liable  to  attend.  Periodical  migraine  and  colic  are  com- 
mon with  such  individuals.  After  long  continuance  the  skin  becomes 
torpid,  dry  and  scaly  or  shriveled,  the  secretions  generally  rank  and 
offensive,  and  the  breath  foetid.  Cardiac  palpitation  occurs  at  inter- 
vals, and  there  is  often  pectoral  pain  or  aching  under  the  scapula. 
Where  the  colon  is  distended  pain  in  the  region  of  the  distention  is 
almost  a  constant  symptom,  this  usually  being  of  a  dull,  aching  char- 
acter, though  there  may  periods  of  acute  aggravation.  Neuralgic 
pains  in  the  testicles,  groins,  down  the  thighs  and  in  the  lumbar 
region  may  be  referable  to  impaction  of  the  lower  portion  of  the 
colon.  Sometimes  symptoms  of  intestinal  obstruction  may  occur, 
and  vomiting  and  cramping  in  the  abdomen  and  other  grave  features 
appear.  In  many  cases  the  bowels  will  move  with  difficulty  every 
three  or  four  days,  the  faeces  being  tenacious  and  pasty  in  char- 
acter or  consisting  of  hardened  lumps  which  are  evacuated  with  pain. 
Sometimes  diarrhoea  is  alternated  with  constipation,  the  irritation  of 


460  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

the  hardened  faeces  giving  rise  to  periodical  catarrh  of  the  intestinal 
mucous  membrane.  Tunneling  of  hardened  faeces  may  sometimes 
occur  and  the  impaction  persist,  while  faecal  material  from  above  is 
passed  through  the  hardened  ring.  Impaction  may  be  detected  by 
palpation,  the  ftecal  accumulations  forming  large  nodulated  masses 
which  are  located  along  the  course  of  the  large  intestine,  forming 
movable  tumors  when  located  in  the  colon.  When  impaction  exists 
near  the  sigmoid  flexure  tenesmus  may  attend,  without  power  to 
evacuate  the  mass. 

Diagnosis. — Constipation  is  a  chronic  condition  hardly  likely 
to  be  mistaken  for  intestinal  obstruction,  as  that  comes  on  suddenly 
unless  it  depends  upon  organic  stricture  of  malignant  or  syphilitic 
character.  Faecal  impaction  may  be  attended  by  severe  pain  and 
vomiting  similar  to  the  symptoms  of  intestinal  obstruction,  but  when 
it  occurs  it  is  not  so  likely  to  be  persistent  and  severe.  In  such 
cases  there  is  apt  to  be  a  history  of  long-continued  constipation 
leading  up  to  it. 

Prognosis. — Functional  retention  of  faeces  is  almost  always 
amenable  to  treatment,  few  cases  persisting  if  rationally  managed. 
In  extreme  old  age  it  may  be  difficult  to  completely  overcome  the 
intestinal  torpor,  though  by  judicious  treatment  faecal  impaction  may 
be  broken  up  and  the  bowels  kept  in  a  fairly  active  state. 

Treatment. — The  habitual  use  of  cathartics  to  overcome  con- 
stipation is  usually  pernicious.  Innervation  of  the  alimentary  canal, 
that  peristalsis  may  be  encouraged,  should  be  aided  by  such  means 
as  morning  and  evening  massage,  the  abdomen  being  kneaded  and 
well  slapped  over  the  bare  skin  for  five  or  more  minutes  on  each 
occasion.  Exercise  should  be  promoted  where  sedentary  habits  are 
necessary  to  any  occupation,  and  plenty  of  fluids  should  be  taken, 
with  avoidance  of  tea  and  coffee.  A  cup  of  hot  water  before  break- 
fast, with  a  cup  of  weak  cocoa  at  that  meal,  will  assist  in  promoting 
daily  evacuation,  especially  if  attention  be  paid  to  regular  and  daily 
effort  at  stool.  Where  there  is  intestinal  torpor  a  single  drop  of 
tincture  or  fluid  extract  of  nux  vomica  in  the  morning,  taken  in  a 
glass  of  cold  or  hot  water,  is  useful.  Copious  enemata  of  strong 
salt  water,  employed  just  after  breakfast  or  dinner,  regularly  every 
day,  may  be  tried  in  stubborn  cases.  The  use  of  galvanism  with  the 
salt-water  electrode  is  the  most  effective  agent  known  in  permanently 
curing  intestinal  torpor.  It  should  be  employed  once  or  twice  a 
week  for  several  months,  and  afterward  once  a  fortnight  for  a  few 
times,  until  its  good  effect  becomes  permanent. 

The  common  cause  of  chronic  constipation  is  orificial  irritation. 
All  bad  cases  should  be  subjected  to  a  rigid  examination,  for  the 
purpose  of  detecting  and  correcting  such  a  condition.  After  this 


DISEASES  OF  THE  INTESTINES.  461 

has  been  accomplished  the  use  of  the  salt-water  electrode  should 
follow,  as  has  already  been  suggested.  Faecal  impaction  may  some- 
times be  broken  up  by  judicious  manipulation  of  the  hardened  masses 
through  the  abdominal  walls,  frequent  use  being  made,  meantime,  of 
the  salt-water  electrode  with  galvanism.  Where  impacted  faeces 
accumulate  in  the  rectum  and  cannot  otherwise  be  dislodged,  they 
should  be  broken  up  with  the  finger,  while  the  patient  is  under  gen- 
eral anaesthesia. 

The  diet  should  consist  largely  of  vegetables,  coarsely  ground 
cereals,  fruits,  especially  cooked  fruits,  and  plenty  of  water.  Much 
lean  meat  should  be  avoided,  as  well  as  eggs,  milk,  sweets,  puddings, 
pastries,  fried  foods,  condiments,  rich  gravies,  curry,  sauces,  pickles, 
nuts,  tea  and  all  alcoholic  liquors. 

INTESTINAL  COLIC. 

Definition. — Pain  in  the  intestines  of  functional  origin  arising 
from  spasmodic  contraction  of  the  muscular  coats  of  the  bowel. 

Etiology. — Intestinal  colic  is  a  neurosis,  due  to  hypersesthesia 
of  the  nerves  supplying  the  intestinal  canal  arising  from  some  excit- 
ing influence,  such  as  the  presence  of  irritating  secretions  or  indiges- 
tible substances  in  the  alimentary  tract,  dilatation  of  some  part  by 
fsecal  accumulation,  gases,  intestinal  worms,  congestion  from  cold, 
rheumatism,  gout,  or  hypersesthesia  of  the  terminal  nerves  through 
the  effect  of  systemic  poisoning  by  lead,  copper,  or  alcohol.  Liabil- 
ity to  it  decreases  with  advancing  age.  Women  are  more  subject  to 
it  than  men. 

Pathology. — No  appreciable  morbid  changes  occur. 

Symptoms. — The  attack  is  usually  abrupt,  though  it  may  be 
preceded  by  flatulence,  nausea,  borborygmus,  chilliness  and  irrita- 
bility of  temper.  The  pain  is  abrupt  in  its  onset,  and,  though  it 
may  be  continuous,  is  marked  by  excerbations,  during  which  the 
patient  is  beut  forward  or  rolls  about  in  agony,  with  groanings  and 
cries  of  pain.  The  abdominal  muscles  are  now  rigid,  the  bowels  are 
knotted  and  the  face  is  drawn.  The  patient  seeks  to  find  relief  by 
pressure  upon  the  abdomen,  either  with  his  hands  or  by  lying  on 
hia  face.  The  abdomen  is  not  sensitive  to  pressure  and  there  is  no 
soreness  after  the  subsidence  of  the  attack.  There  is  absence  of 
fever,  the  pulse  is  small  and  feeble  and  the  extremities  aro  often 
cold,  especially  during  the  paroxysms.  The  kidneys  may  be  dis- 
turbed, a  great  quantity  of  limpid  urine  being  voided  during  the 
attack  and  there  may  even  be  vesical  tenesmus.  There  is  some- 
times vomiting  (bilious  colic)  and  constipation  is  the  general  rule, 
hough  diarrhoea  may  be  present.  If  allowed  to  continue  the  dis- 


462  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

ease  will  usually  terminate  iu  the  escape  of  flatus,  either  alone  or 
accompanied  by  diarrhoea.  Symptoms  of  collapse  may  attend  aggra- 
vated cases.  In  malarious  districts  the  attacks  may  be  periodical, 
returning  as  regularly  as  an  attack  of  ague,  lasting  several  hours  and 
then  disappearing,  until  the  second  or  third  day  afterward.  In 
rheumatic  colic  there  are  usually  accompanying  pains  in  other  parts, 
with  tendency  to  metastasis.  Bilious  colic  is  the  form  in  which 
nausoa  and  vomiting  are  prominent  symptoms.  Vitiated  secretions 
or  gastric  complications  are  responsible  for  this  phase.  The  vomited 
matters  are  greenish  or  yellow.  The  tongue  may  be  coated,  and 
there  may  be  slight  fever,  suggesting  more  or  less  constitutional  dis- 
turbance. This  form  may  be  more  persistent  than  ordinary  flatulent 
colic,  and  jaundice  may  appear  during  its  development,  the  hepatic 
symptoms  persisting  for  several  days.  It  is  most  common  in  malari- 
ous districts.  Colic  frequently  arises  from  a  rheumatic  condition, 
in  which  case  metastasis  to  other  parts  is  likely  to  occur. 

Colica  pictonum  or  lead  colic  affects  those  who  have  been  using 
lead  in  some  avocation  for  a  long  time,  such  as  painters,  composi- 
tors, type  founders,  stereotypers  or  lead  miners.  Sometimes  acci- 
dental poisoning  may  occur  from  the  use  of  water  which  has  been 
carried  through  a  lead  pipe  or  in  some  such  way.  The  pain  comes 
on  gradually  in  this  form  of  colic,  the  paroxysms  being  moderately 
severe  at  first,  but  increasing  in  severity  and  frequency  until  intense 
paroxysms  follow  each  other  with  rapidity.  The  colic  is  located 
principally  about  the  navel,  and  cramps  of  the  extremities  may  attend 
the  paroxysms.  The  abdomen  is  flattened  and  hardened,  the  intes- 
tines are  knotted  and  rigid,  and  there  is  obstinate  constipation, 
which  resists  the  action  of  all  ordinary  cathartics.  Kelapses  are 
easily  excited  by  the  least  indiscretion  in  diet  or  exposure  to  changes 
of  temperature.  The  patient  is  sallow,  anaemic,  more  or  less  debili- 
tated, and  the  pulse  is  slow.  A  distinctive  feature  of  the  case  is  a 
deep  blue  dotted  line  along  the  margins  of  the  gums,  formed  by  a 
combination  of  sulpheretted  hydrogen  arising  from  decomposing  food 
with  the  lead  in  the  circulation.  There  is  often  paralysis  of  the 
extensors  of  the  forearm,  causing  the  wrist  to  drop  when  the  arm  is 
extended,  or  optic  neuritis  resulting  in  amaurosis,  and  tendency  to 
epileptic  convulsions. 

Copper  colic  differs  from  lead  colic  in  that  the  pain  is  increased 
by  pressure,  there  is  diarrhoea  of  greenish  evacuations  instead  of 
constipation,  and  the  abdomen  is  distended  instead  of  contracted. 
The  line  along  the  edge  of  the  gums  is  purplish  instead  of  blue,  and 
the  specific  influence  of  copper  upon  the  laryngeal  and  bronchial 
muscles  is  manifested  by  spasm  of  these  organs  attended  by  dysp- 


DISEASES  OF  THE  INTESTINES.  463 

ncea.  In  both  lead  aiid  copper  poisoning  there  are  elements  of  chro- 
nicity  not  observed  in  flatulent  colic. 

Diagnosis. — Peritonitis  will  hardly  be  confounded  with  colic, 
as  it  is  a  disease  attended  by  marked  febrile  reaction  and  a  tense, 
wiry  pulse,  with  tenderness  011  pressure,  while  the  opposite  is  tha 
case  in  colic,  the  pain  being  paroxysmal  instead  of  steady  as  in  peri- 
tonitis; and  these  peculiarities  will  distinguish  the  disease  from  all 
other  abdominal  complaints. 

Prognosis, — The  prognosis  is  almost  universally,  favorable. 
Convulsions  may  terminate  unfavorably  in  children,  though  such  a 
result  is  rare,  and  rupture  of  the  intestine  may  occur  in  exceptional 
cases  from  violent  distention  of  gases. 

Treatment. — A  specific  remedy  in  most  cases  of  flatulent  colic 
is  colocyntli.  The  second  or  third  decimal  dilution  of  the  specific 
medicine  may  be  used,  half  a  traspoonful  being  added  to  four  ounces 
of  water  and  a  teaspoonful  of  the  mixture  being  administered  every 
fifteen  minutes  until  the  pain  ceases,  which  will  usually  be  after  the 
second  or  third  dose.  Many  Eclectics  prefer  to  employ  the  old 
remedy,  dioscorea;  and  this  is  indeed  good,  the  dose  being  ten  or 
fifteen  drops  of  the  specific  medicine  in  a  little  water  every  fifteen 
minutes,  until  relief  follows. 

In  rheumatic  colic  full  doses  of  a  strong  decoction  of  cimicifuga  root 
is  best,  the  decoction  being  administered  in  wineglassful  doses  every 
half-hour,  until  its  full  effects  are  exerted  upon  the  system.  An 
alcoholic  vapor  or  cabinet  vapor  bath  assists  materially  here  in  shorten- 
ing the  course  of  treatment.  Where  periodicity  is  marked  and  the 
attacks  persistently  return  with  regularity,  the  use  of  antiperiodic 
doses  of  quinine  or  other  antiperiodic  is  eminently  demanded.  When 
constipation  is  present  a  decoction  of  rhamnus  cal.  is  more  relia- 
ble and  speedier  in  action  than  cimicifuga  in  rheumatic  colic.  The 
decoction  may  be  taken  in  wineglassful  doses,  repeated  every  hour 
until  its  cathartic  action  is  developed;  then  at  longer  periods. 
Gouty  colic  depends  upon  a  gradually  acquired  constitutional  con- 
dition which  requires  long-continued  treatment  for  the  gouty  habit, 
as  suggested  under  that  disease. 

Lead  colic  demands,  for  relief,  prompt  and  urgent  measures,  and 
rigid  abstinence  from  avocations  or  surroundings  which  tend  to  fur- 
ther contaminate  the  system.  The  obstinate  constipation  must  be 
relieved,  and  for  this  purpose  it  is  useless  to  depend  upon  ordinary 
cathartics.  Croton  oil  is  about  the  only  drug  that  will  accomplish 
the  purpose  here,  and  it  should  be  giveii  cautiously,  in  small  but  oft- 
repeated  doses,  until  the  purpose  is  attained.  One  drop  of  croton 
oil  and  one  grain  of  powdered  opium  may  be  combined,  and  a  dose 
given  every  two  hours  until  the  desired  action  occurs.  Valuable 


464  DISEASES  OF  THE  DIGESTIVE  OKGANS. 

assistance  may  be  derived  from  the  use  of  galvanism  with  the  salt- 
water electrode  in  the  lower  bowel,  though  this  is  not  necessary. 
Dioscorea,  in  combination  with  gelsemium  (sp.  med.  dioscorea  gtt. 
xv,  sp.  med.  gelsemium  gtt.  x),  is  excellent  to  alternate  with  the  cro- 
ton  oil  to  alleviate  the  severe  pains.  As  soon  as  the  bowels  move  the 
pain  ceases  for  the  time,  and  further  treatment  should  be  directed  to 
the  prevention  of  a  recurring  attack.  The  salt-water  enema  with 
galvanism  should  be  employed  to  promote  regular  evacuations,  and 
a  milk  diet  should  be  used  for  weeks — until  the  lead  has  been  re- 
moved from  the  system.  This  is  supposed  to  be  furthered  by  the 
action  of  iodide  of  potassium,  which  combines  with  the  lead  in  the 
system  to  form  a  soluble  lead  salt,  which  may  be  removed  by  the 
kidneys.  If  the  patient  cannot  abandon  his  avocation  or  remove 
from  the  influences  of  surroundings  which  expose  him  to  possibility 
of  contamination,  he  should  try  to  prevent  the  entrance  of  the  drug 
into  the  system.  As  this  is  liable  to  occur  during  eating,  a  small 
dose  of  diluted  sulphuric  acid  should  be  tak  n  during  or  after 
meals,  this  uniting  with  the  lead  in  the  stomach  to  form  an  in- 
soluble compound  of  the  metal,  which  cannot  enter  the  circulation. 
Copper  colic  should  be  treated  similarly  to  other  forms,  except 
that  as  there  is  diarrhoea  there  will  be  no  call  for  cathartics.  Sul- 
phur vapor  batJis  may  assist  in  removing  the  copper  from  the  system, 
and  cabinet  vapor  baths  will  alleviate,  to  some  extent,  the  severe 
pain.  A  milk  diet  should  be  adhered  to  for  a  long  time  after  con- 
valescence. 

ESTIVAL  INFANTILE  ENTERITIS. 

Synonym. — Summer  Complaint  of  Children. 

Etiology. — Infants  are  peculiarly  liable  to  diarrhoeal  diseases 
during  the  hot  months  of  summer  and  early  fall,  mauy  perishing 
every  season  from  different  forms  of  enteritis.  The  death  rate  begins 
in  May  and  gradually  rises  into  July,  when  it  curves  downward 
through  August  and  September.  Three  important  factors  operate  to 
bring  about  this  state  of  affairs,  namely,  the  want  of  development  of 
the  digestive  organs,  the  character  of  the  food  consumed,  and  the 
development  of  bacteria  in  the  intestinal  canal.  Until  the  deciduary 
teeth  are  developed  the  salivary  glands  of  infants  are  incapable  of 
digesting  starchy  food,  and  artificially  fed  children — those  most  lia- 
ble to  be  affected  with  summer  diarrhoea — are  very  apt  to  receive 
such  aliment,  unless  the  mother  or  nurse  has  been  well  instructed 
upon  the  subject;  and  this  is  not  apt  to  be  the  case  among  the 
ignorant  and  poor,  the  class  of  people  most  liable  to  suffer.  Hot 
weather  encourages  fermentation — the  development  of  bacteria — 


DISEASES  OF  THE  INTESTINES.  465 

which  may  prove  provocative  of  serious  intestinal  disease.  Milk 
or  other  food  that  is  least  tainted  is  almost  sure  to  contain  many 
varieties  of  microbes,  which,  when  they  develop  within  the  aliment- 
ary canal,  originate  toxines  which  may  prove  rapidly  destructive  to 
life.  Most  cases  of  mortality  from  infantile  diarrhoea  occur  between 
the  ages  of  six  and  eighteen  months,  and  a  very  large  majority  in 
artificially  fed  children;  the  percentage  of  babies  fed  exclusively  at 
the  mother's  breast  affected  being  insignificant.  The  stools  of 
healthy  nursing  children  contain  numerous  bacilli  and  micrococci 
which  seen  to  thrive  when  an  exclusive  milk  diet  is  used,  and  this 
without  detriment  to  the  host,  milk  diet  seeming  to  be  the  provision 
under  which  they  exist;  one  species,  the  bacterium  lactis  serogenes, 
being  supposed  to  subsist  upon  the  sugar  of  milk,  while  it  devel- 
ops in  the  upper  portion  of  the  alimentary  canal.  Another  promi- 
nent form  is  the  bacterium  coli  commune,  which  develops  in  the 
lower  intestine.  Other  forms  are  present  in  health,  but  when  en- 
teritis arises  the  number  is  greatly  increased,  the  morbid  products 
then  developed  probably  acting  as  toxines,  as  infantile  diarrhoea 
in  most  cases  is  evidently  more  than  a  local  disease.'  It*  children 
of  the  poor  in  cities,  where  fresh  milk  is  difficult  to  obtain  and 
where  artificial  foods  are  largely  used,  .  is  where  infantile  diar- 
rhoea marks  its  greatest  ravages,  though  bottle-fed  babies  in  rural 
districts  are  also  frequently  affected.  Pure  air,  containing  a  large 
amount  of  ozone,  neutralizes  to  considerable  extent  the  virulence  of 
the  seasonal  influence.  On  the  sea  coast  and  in  mountain  altitudes 
the  disease  is  much  less  common.  Around  San  Francisco  Bay  there 
is  almost  a  complete  absence  of  summer  complaint  among  children, 
and  when  it  occurs  it  must  be  managed  very  badly  if  the  disease 
do  not  prove  readily  amenable.  Oakland,  on  San  Francisco  Bay, 
it  seems  to  me,  is  a  paradise  for  bottle-fed  babies. 

Pathology, — The  mucous  membrane  of  both  large  and  small  in- 
testines is  swollen  and  covered  with  catarrhal  secretion,  and  the 
lymph-follicles  are  enlarged,  filled  with  proliferating  cells  and,  in 
protracted  cases,  ulcerated.  Occasionally  there  is  croupous  exuda- 
tion on  the  mucous  membrane  of  the  colon  and  lower  ileum,  and, 
in  such  cases,  extensive  ulceration  may  occur.  Lesions  of  the  nerv- 
ous system  are  not  common,  though  -in  fatal  cases  effusion  often 
occurs  prior  to  death.  The  spleen  and  lungs  may  be  congested, 
though  such  complications  are  not  common.  The  liver  and  mesen- 
teric  glands  are  often  congested. 

Three  varieties  of  summer  complaint  are  described,  all  being  due 
to  similar  causes,  and  all  presenting  similar  puthological  conditions, 
though  the  symptoms  are  markedly  at  variance.  They  are  (1)  acute 
dyspeptic  diarrhoea,  (2)  cholera  infant  um  and  (3)  acute  entero-colitis. 

31 


466  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

ACUTE  DYSPEPTIC  DIARRHCEA. — This  form  of  summer  complaint  is 
characterized  by  the  presence  of  undigested  foods  and  curds  in  the 
evacuations,  which  are  more  frequent  than  normal,  and  of  abnormal 
color,  being  sometimes  greenish,  sometimes  greenish-yellow,  again 
grayish-yellow,  and  often  of  a  variety  of  colors.  The  disease  comes 
on  gradually,  the  patient  being  peevish,  craving  food  and  manifest- 
ing restlessness  at  night.  In  other  cases  the  onset  may  be'  abrupt, 
and  there  may  be  colicky  pains,  vomiting  and  rapid  rise  of  tempera- 
ture, until  104°  or  105°  F.  is  reached.  Sometimes  active  determina- 
tion of  blood  to  the  brain  with  convulsions  marks  the  onset.  After 
the  initiatory  symptoms  the  case  may  continue  in  the  form  of  lien- 
teric  diarrhoea,  with  greenish,  tenacious  discharges  of  faecal  material, 
mixed  with  gas  and  undigested  food,  or  it  may  finally  merge  into  a 
case  of  cholera  infautum  or  entero-colitis.  Such  attacks  may  occur 
in  very  young  infants  as  the  result  of  improperly  prepared  cow's 
milk,  or  in  older  infants  as  the  result  of  the  ingestion  of  starchy  or 
farinaceous  food,  or  unripe  fruit.  In  this  disease  the  stools  are  tena- 
cious and  pasty,  with  occasional  mixture  of  serous  fluid,  mucus  rarely 
being  present.  '  Though  there  may  be  griping  pain  at  the  time  of 
evacuation,  there  is  no  tenesmus. 

CHOLERA  INFANTUM. — In  this  form  of  summer  complaint  there  are 
profuse  watery  evacuations,  which  are  expelled  forcibly  with  a  gush, 
and  the  vomiting,  which  usually  attends,  is  projectile,  the  ejected 
material  being  also  watery  in  character.  The  disease  is  not  very 
common  as  compared  with  the  number  of  other  cases  of  summer 
complaint  which  occur,  though  it  is  the  gravest  form  of  the  disease. 

The  sympioms  are  very  much  like  those  of  cholera  morbus  in 
adults,  though  the  disease  is  more  likely  to  terminate  fatally.  There 
are  simultaneous  vomiting  and  purging  in  many  instances,  though  at 
other  times  the  vomiting  may  precede  the  purging.  The  stools  may 
contain  faecal  material  and  be  offensive  in  odor  at  first,  but  they  soon 
become  watery  and  odorless,  and  the  patient  becomes  rapidly  pros- 
trated. The  extremities  become  cold,  the  skin  wrinkled,  cold  and 
clammy,  the  nails  blue,  the  countenance  pinched  and  pallid  and  the 
tissues  greatly  shrunken.  Though  the  surface  is  cold  the  rectal  tem- 
perature varies  from  102°  to  107°  F.  and  the  pulse  is  rapid  and 
thready.  There  is  extreme  thirst  and  restlessness,  and  the  patient 
may  scream  with  agony  from  severe  cramping  pain  at  the  time  of 
evacuation.  Liquids,  foods  and  medicines  are  ejected  as  soon  as 
swallowed  in  many  instances,  even  a  teaspoonful  of  water  exciting 
responsive  vomiting.  As  the  disease  progresses  cerebral  symptoms 
may  appear,  the  temperature  becoming  very  high,  and  the  patient 
may  die  in  convulsions  within  a  few  hours.  In  other  cases  the  vom- 
iting and  purging  may  cease  and  the  child  pass  into  a  comatose  con. 


DISEASES  OF  THE  INTESTINES.  467 

dition,  in  which  state  it  may  remain  for  several  days  without 
change,  lying  with  the  head  retracted,  with  irregular  respiration  and 
convulsive  symptoms  (hydroencephalon). 

ACUTE  ENTERO-COLITIS. — This  form  of  summer  complaint  is  marked 
by  the  frequent  evacuation  of  dejections  of  mucus  mixed  with  faecal 
material,  and  often  streaked  with  blood,  the  evacuations  being  at- 
tended by  painful  straining  (tenesmus)  and  preceded  by  pains  along 
the  course  of  the  colon  or  about  the  umbilicus.  Frequently  there  is 
gastric  irritability,  the  tongue  being  red  at  the  tip  and  pointed,  fluids 
and  foods  being  rejected.  This  is  the  common  form  which  estival 
infantile  enteritis  assumes,  and  it  usually  follows  acute  dyspeptic 
diarrhoea.  The  follicles  of  the  ileum  and  colon  are  the  anatomical 
parts  most  involved  in  pathological  chauge,  and  the  term  "follicular 
enteritis"  is  occasionally  applied  to  it.  Though  usually  a  disease  of 
hot  weather,  this  form  of  enteritis  may  occur  at  any  time  of  the  year. 
The  symptoms  vary  according  to  the  portion  of  the  intestine  affected, 
evacuation  without  marked  tenesmus  attending  when  the  irritation  is 
in  the  lower  portion  of  the  colon  or  in  the  rectum.  After  the  disease 
becomes  established  the  evacuations  are  almost  entirely  mucus  and 
blood,  while  there  is  nearly  complete  arrest  of  faecal  evacuation. 
Sometimes  the  inflammation  of  the  rectum  and  colon  is  so  severe 
that,  instead  of  streaks  of  blood  in  the  mucous  evacuations  the  dis- 
charges appear  to  be  nearly  all  blood,  and  there  is  more  than  ordi- 
narily severe  pain  and  tenesmus  at  time  of  evacuation.  Colicky  pains 
about  the  navel  precede  and  announce  the  time  of  evacuation.  The 
temperature  is  not  usually  so  high  as  in  cholera  infantum,  but  there 
is  constant  elevation  of  temperature,  this  sometimes  assuming  a 
periodical  character  and  manifesting  remissions  and  excerbations, 
the  severity  of  the  intestinal  trouble  corresponding  with  the  period- 
icity. The  number  of  evacuations  vary  from  ten  to  thirty  in  twenty- 
four  hours. 

As  the  disease  progresses  the  patient  becomes  peevish  and  fret- 
ful, and  gradual  emaciation  ensues.  When  badly  treated  the  disease 
may  continue  for  weeks,  the  evacuations  gradually  becoming  puru- 
lent and  general  wasting  of  the  tissues  (marasmus)  attending,  the 
skin  becoming  dry  and  wrinkled,  the  eyes  sunken,  the  face  pallid  with 
hectic  flush,  and  the  child  generally  prostrated,  with  irritable  stom- 
ach. Death  from  convulsions  frequently  closes  the  scene. 

Treatment. — An  important  consideration  in  the  treatment  of 
any  form  of  summer  complaint  of  children  is  rest  for  the  alimentary 
canal.  As  milk,  otherwise  than  human  breast  milk,  is  almost  certain 
to  curdle  in  the  stomach  and  remain,  to  considerable  extent,  undi- 
gested thereafter  unless  pancreatinized  before  administration,  and  as 
such  food  doubtless  contains  many  causal  elements  of  the  disease  (if 


468  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

not  the  specific  elements),  it  is  a  wise  plan  to  withdraw  it  entirely 
for  a  time  as  a  diet  and  substitute  such  food  as  cannot  furnish 
any  solid  material  during  digestion  to  irritate  the  alimentary  canal. 
Barl»y-ioater  or  rice-water  may  be  substituted  for  the  first  thirty-six 
hours  or  longer,  in  children  a  year  or  more  of  age,  these,  to  say  the 
least,  contributing  no  additional  source  of  danger.  Strict  attention 
should  be  paid  to  the  avoidance  of  fermentative  action,  all  food  being 
kept  in  a  refrigerator,  or  sterilized  each  time  before  use.  When  the 
disease  is  severe  and  protracted,  fresh  meat  broths  may  be  sub- 
stituted. In  younger  children  the  use  of  Horlick's  malted  milk 
(which  is  so  combined  with  cereals  as  to  prevent  coagulation)  may 
sometimes  prove  better  than  broths  or  barley-water,  the  food  being 
carefully  sterilized  at  each  feeding,  and  the  periods  being  regulated 
to  the  requirements  of  individual  cases,  and  not  allowed  too  often. 
Eudoxine  or  ghjcozone  may  assist  in  arresting  fermentation. 

The  milk  of  pregnant  mothers  is  sometimes  very  injurious,  occa- 
sionally, apparently,  being  a  provoking  cause  of  the  complaint.  I 
have  found  it  necessary  to  remove  the  child  from  the  breast  on  this 
account,  and  in  one  case  where  death  seemed  imminent  immediate 
improvement  followed  when  Mellin's  food  was  substituted  for  the 
mother's  breast.  When  cow's  milk  is  to  be  used,  it  should  be  care- 
fully sterilized  and  afterward  combined  with  lime-water,  in  order  that 
the  curd  may  be  well  broken  up  and  acidity  removed — a  tablespoon- 
ful  of  lime-water  to  eight  ounces  of  milk.  Nothing  but  milk  sugar 
should  be  used  for  sweetening  the  food  of  bottle-fed  babies  less 
than  a  year  old. 

The  medicinal  treatment  of  dyspeptic  diarrhoea  will  consist  of  im- 
mediate evacuation  of  the  bowels,  the  neutralizing  cordial  of  the 
Ameri*  an  Dispensatory  being  an  excellent  article  for  this  purpose. 
Following  this,  one  or  two  drops  of  hydrozone  in  a  drachm  of  dis- 
tilled water  may  be  administered  three  or  four  times  daily  to  neu- 
tralize fermentation  and  destroy  toxic  germs.  If  the  greenish,  tena- 
cious stools  persist  after  this,  two-grain  doses  of  mercurius  dulcis 
may  be  administered  every  three  or  four  hours  until  several  doses 
have  been  administered,  this  remedy  usually  being  capable  of  alter- 
ing the  conditions  so  that  return  to  normal  fsecal  evacuations  follows. 
Sometimes  two-  or  three-drop  doses  of  the  3x  dilution  of  mercurius 
cor.  will  answer  better,  and  at  others  five  grains  of  sodium  sulph.  in 
four  ounces  of  water,  dose  a  teaspoonful  every  hour,  will  answer  bet- 
ter. Minute  doses  of  sulpho-carlonate  of  zinc  are  also  excellent  here. 

In  cholera  infantum  the  hydrozone  should  be  used  as  already  sug- 
gested, and  to  arrest  the  gushing  discharges  and  projectile  vomiting 
half  a  drachm  of  veratrum  album,  3x  dilution,  may  be  added  to  four 
ounces  of  distilled  water  and  a  teaspoonful  administered  every  fif- 


DISEASES  OF  THE  INTESTINES.  469 

teen  minutes  or  half-hour.  If  this  fails  to  control  the  watery  dis- 
charges, or  if  it  is  not  immediately  obtainable,  a  decoction  of  the 
fresh  trigeron  canadense  plant  may  be  allowed,  the  child  here  drink- 
ing it  with  avidity.  It  may  be  given  often  and  freely.  The  specific 
medicine  may  answer  as  well,  though  I  have  never  tried  it  for  the 
purpose.  When  hydroencephaloid  symptoms  appear  aconite  and  rlius 
tox.  should  be  administered,  two  or  three  drops  of  Lloyd's  aconite 
and  eight  or  ten  drops  of  rlius  tox.  being  added  to  four  ounces  of 
water  and  a  teaspoonful  given  every  hour.  Where  symptoms  of  coma 
are  marked  and  the  pulse  is  small,  feeble  and  compressible,  two  or 
three  drops  of  specific  belladonna  may  be  used  instead  after  the 
same  manner  as  the  aconite  and  rhus  tox.  In  other  words,  two  or 
three  drops  of  specific  belladonna  may  be  added  to  a  half  glass  of 
water,  a  teaspoonful  of  this  to  be  given  every  hour  until  comatose 
symptoms  subside. 

In  the  treatment  of  entero-colitis  quite  a  wide  range  of  remedies 
may  be  required,  though  a  few  are  usually  sufficient.  Aconite  and 
ipecac  answer,  with  proper  feeding,  in  relieving  most  cases  and  per- 
fecting a  cure.  Add  two  or  three  drops  of  aconite  and  ten  or  fifteen 
of  specific  ipecac  to  four  ounces  of  water  and  order  a  teaspoonful 
every  hour.  Sometimes  the  abdominal  pain  is  excessive  and  attracts 
special  attention,  demanding  something  more  specific  for  its  relief. 
Then  we  will  administer  colocynth  3x  dilution,  half  a  drachm  in  four 
ounces  of  water,  a  teaspoonful  every  hour  or  oftener  if  desired,  until 
this  phase  is  removed.  Colocynth  is  especially  desirable  if  there  be 
much  blood  in  the  stools.  In  these  cases  time  is  an  essential  ele- 
ment of  success.  Several  days  may  be  required  to  effect  a  cure, 
the  first  favorable  symptom  being  a  lessening  of  the  severity  of  the 
Buffering  during  and  between  stools,  and  the  next  adimunition  in  the 
number  of  stools.  In  malarious  districts  there  will  be  a  marked 
periodicity  which  will  demand  arseniate  of  quinia  3x,  and  this  remedy 
may  be  used  with  good  judgment  in  any  case  where  malaria  is  liable 
to  be  present. 

Sometimes  there  is  evidence  of  necrotic  tendency,  the  evacua- 
tions containing  shreds  of  mucous  membrane,  false  membrane  and 
dark  sanious  discharges  (prune-juice),  and  the  patient  evincing  typhoid 
symptoms.  Here  we  may  think  of  baptisia  or  ec/tinacea,  the  latter 
remedy  being  usually  more  appropriate,  though  sulpho-carbolate  of 
sodium  may  often  supersede  other  remedies  in  such  instances. 

Where  the  disease  runs  into  a  chronic  form  and  the  discharges 
become  thin  and  watery  with  muco-purulent  admixture,  the  patient 
thin  and  emaciated  with  wrinkled  skin,  constant  fretfulness  and  other 
symptoms  of  marasmus,  tncrcurius  cor.  6x  is  an  excellent  remedy  for 
its  relief.  It  is  also  excellent  in  the  early  stages,  where  the  stools 


470  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

are  greenish  in  color.  In  marasmus  following  this  condition  an  al- 
most indispensable  element  of  rapid  and  satisfactory  success  is  the 
tonic  farad ic  treatment,  general  arrest  of  all  unpleasant  symptoms 
rapidly  following  its  adoption. 

Several  other  important  remedies  for  this  disease  and  cholera 
infautum  may  be  found  in  Dynamical  Therapeutics,  a  work  almost 
indispensable  for  the  study  of  modern  materia  medica. 

VIH.  DISEASES  OF  THE  MESENTERY. 

MISCELLANEOUS  AFFECTIONS. 

THE  mesentery  is  liable  to  serious  affections,  which  are  of  suffi- 
cient importance  to  merit  attention  in  a  work  of  this  character. 

The  mesenteric  arteries  are  subject  to  embolism  and  thrombosis, 
and  when  this  occurs  the  bowel  in  the  territory  supplied  by  an 
affected  vessel  undergoes  a  condition  of  infarction.  When  only  a 
small  branch  is  affected  the  condition  may  not  be  serious,  and  restor- 
ation may  occur  without  the  development  of  serious  symptoms. 
When  larger  vessels  are  blocked,  however,  severe  pain  in  the  abdo- 
men, with  tympanities,  nausea  and  vomiting,  soon  arises.  Diar- 
rhoea occurs  as  a  rule,  the  stools  being  thin  and  watery  and  some- 
times tinged  with  blood.  Thrombosis  of  the  superior  meseuteric 
artery  is  followed  by  infarction  of  nearly  the  entire  length  of  the 
small  bowel,  and  rapidly  fatal  conditions  follow.  The  treatment  can 
only  be  of  a  surgical  nature,  resection  of  the  bowel  being  suggested. 
Where  the  infarction  involves  but  a  small  section  of  the  intestine 
resection  offers  hopes  of  relief. 

The  meseuteric  veins  are  subject  to  dilatation,  sacculatiou  and 
calcification,  distention  being  due  to  portal  obstruction.  This  may 
occur  in  cirrhosis  of  the  liver  or  in  any  other  condition  in  which 
the  onward  motion  of  the  blood  toward  the  portal  circulation  is 
impeded. 

Suppuration  of  the  mesenteric  veins  is  also  liable  to  occur,  and 
it  is  a  usual  attendant  of  inflammation  of  the  vena  portae.  Ex- 
treme dilatation  of  the  mesenteric  veins  then  follows,  and  large 
quantities  of  pus  accumulate,  until  the  mesentery  appears,  upon 
inspection,  like  a  bag  of  pus.  Upon  careful  examination,  however, 
the  pus  will  be  found  to  be  confined  within  venous  channels  which 
have  undergone  great  dilatation.  The  symptoms  resemble  those 
of  pylephlebitis,  though  there  is  greater  abdominal  distention.  Treat- 
ment is  of  little  avail. 

Cysls  of  the  mesentery  are  not  of  unfrequent  occurrence.     Quite 


DISEASES  OF  THE  LIVER.  471 

a  variety  of  morbid  formations  of  this  character  may  occur  here. 
They  may  be  chylous,  serous,  sanguineous,  hyatid  or  dermoid.  They 
may  vary,  from  the  size  of  an  orange  to  immense  masses  occupy- 
ing and  distending  the  entire  abdomen.  They  may  develop  slowly 
or  rapidly,  from  a  few  months  to  ten  or  twelve  years  being  the 
varying  time  occupied  in  their  growth  in  different  cases.  The  gen- 
eral health  is  not  much  affected  in  these  cases,  colicky  pains  and 
constipation,  with  enlargement  of  the  abdomen,  being  the  princi- 
pal symptoms.  The  diagnosis  is  obscure,  such  diseases  as  ovarian 
tumor,  floating  kidney,  hydronephrosis  and  ornental  cysts  being 
liable  to  be  confounded  with  it.  No  specific  treatment  is  kuown. 

The  chyle  vessels  are  subject  to  various  morbid  conditions.  En- 
largement of  the  ducts  in  the  mucous  and  submucous  tissues  of 
the  intestine  and  stomach  occasionally  occur.  Sometimes  these 
are  cystic,  sometimes  varicose,  and  sometimes  cavernous.  Extrav- 
asation of  chyle  into  the  tissues  of  the  mesentery  sometimes  occurs. 


IX.   DISEASES  OP  THE  LIVER. 

JAUNDICE. 

Synonym. — Icterus. 

Definition. — Jaundice  can  hardly  be  classed  as  a  distinct  dis- 
ease, as  it  may  depend  upon  a  variety  of  pathological  conditions. 
However,  as  it  is  a  striking  condition  of  the  system  frequently  pres- 
eut,  a  consideration  of  the  various  phases  attending  it  under  one 
grouping  will  be  not  only  proper,  but  essential.  The  term  "jaun- 
dice" or  "icterus"  belongs  to  conditions  of  the  system  marked  by 
the  presence  of  bilirubin  in  the  general  circulation  and  in  certain 
of  the  secretions,  such  as  the  urine  and  perspiration,  and  character- 
ized by  yellow  hue  of  the  skin,  conjunctiva,  hard  palate,  etc. 

Etiology, — Two  forms  of  jaundice  occur,  one  being  due  to 
obstruction  of  the  bile-ducts  and  the  other  to  imperfect  service  of 
the  hepatic  cells.  When  the  bile  is  secreted  by  the  hepatic  cells 
but  is  retained  in  the  biliary  ducts,  to  be  afterward  absorbed  by  the 
lymphatics  and  carried  to  the  blood  through  the  thoracic  duct,  the 
condition  is  termed  "hepatogenous  or  obstructive  jaundice."  This 
may  be  due  to  tumefaction  of  the  mucous  membrane  lining  the  bili- 
ary ducts,  especially  of  the  common  bile-duct— that  portion  which 
lies  in  the  wall  of  the  duodenum — the  condition  often  being  the 
result  of  inward  extension  of  congestion  of  the  intestinal  nmcosa. 
At  other  times  the  obstruction  may  be  due  to  lodgment  of  biliary 
calculi,  or  iu  exceptional  instances  to  such  parasites  as  the  distoma 


472  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

hepaticum  or  echiuococcus  iii  the  common  bile-duct,  and  again  to 
pressure  from  tumors,  such  as  cancer  of  the  pylorus,  tumors  of  the 
pancreas,  liver,  or  other  abdominal  tumors.  The  gravid  uterus  may 
exert  such  pressure,  as  well  as  aneurisms.  Inspissated  mucus  may 
obstruct  the  opening  of  the  biliary  ducts  where  there  is  catarrh 
of  their  liuiug  membrane,  it  being  remembered  that  the  bile-pressure 
from  the  secretory  action  of  the  cells  in  the  ducts  is  very  low,  and 
that  the  lymphatics  readily  take  it  up  if  there  does  not  exist  a  favor- 
able way  of  exit. 

When  there  is  lack  of  power  upon  the  part  of  the  biliary  cells 
to  separate  the  coloring  material  from  the  hepatic  circulation  the 
condition  is  termed  "hematogenous  or  uonobstrusive  jaundice." 
In  this  form  there  may  be  an  excess  of  blood  destruction,  as  in  mala- 
ria, yellow  and  typhoid  fever,  epidemic  jaundice,  pyaemia,  snake- 
poisoning  and  poisoning  from  phosphorus  and  other  drugs,  the 
hematoidin  resulting  being  identical  with  the  coloring  material  of 
the  bile  (bilirubin).  Necrosis  of  the  hepatic  cells  may  prevent  sep- 
aration of  this  substance,  as  in  case  of  acute  yellow  atrophy,  yel- 
low fever,  or  such  other  infectious  diseases  as  pyaemia,  etc.;  or,  the 
destruction  of  red  blood-corpuscles  may  be  so  extensive  that  an  over- 
flow occurs,  and,  while  a  normal  amount  may  be  separated,  a  suffi- 
cient quantity  appears  in  the  general  circulation  to  give  rise  to  a 
jaundiced  condition  of  the  tissues. 

In  icterus  neonatorum  or  the  jaundice  in  infants,  the  first  few  days 
succeeding  birth  may  be  attended  by  jaundice  due  to  effective  clos- 
ure of  the  ductus  venosus,  or  to  lack  of  pressure  in  the  branches  of 
the  portal  vein  due  to  arrest  of  the  placental  circulation.  In  grave 
forms  of  infantile  jaundice  congenital  syphilitic  hepatitis  may  be  a 
cause  of  obstruction,  there  may  be  congenital  closure  or  absence  of 
the  biliary  duct,  or  there  may  be  septicaemia  phlebitis  of  the  hepatic 
veins  from  infection  of  the  umbilical  cord. 

It  is  a  question  with  many  whether  true  jaundice  can  exist  unless 
the  hepatic  cells  have  formed  the  bile  previous  to  its  admixture  with 
the  blood — whether  such  a  disease  as  hematogenous  jaundice  can 
occur.  While  the  coloring  material  of  the  bile  is  identical  with 
hematoidin,  which  may  be  formed  withoiit  passage  through  the  liver, 
the  bile-salts  (glycocholate  and  taurocholate  of  soda)  never  exist 
unless  elaborated  by  the  hepatic  cells.  At  least,  then,  there  is  a 
marked  difference  between  hepatogenous  and  hematogenous  jaun- 
dice in  that  in  the  one  true  bile  circulates  in  the  blood,  while  in  the 
other  only  the  coloring  material,  identical  with  that  of  bile,  is  pres- 
ent without  other  biliary  constituents. 

In  Weil's  disease  (an  acute  infectious  fever  attended  by  jaundice, 
duly  considered  under  specific  infectious  diseases)  there  is  obstruc- 


DISEASES  OF  THE  LIVER.  473 

tion  of  the  biliary  ducts  from  swelling  of  the  liver,  the  clay- colored 
stools  attesting  absence  of  the  coloring  material  of  the  bile  from  the 
intestinal  canal. 

Pathology. — The  morbid  change  which  follows  the  continued 
presence  of  the  bile  in  the  blood  in  hepatogenons  jaundice  is  effusion 
of  bile-stained  serum  which  yellows  nearly  all  the  tissues  of  the 
body.  It  is  asserted  that  the  humors  of  the  eye  and  substance  of 
the  brain  usually  escape.  Even  the  bones  and  teeth  may  be  colored, 
as  well  as  new  pathological  formations.  The  presence  of  the  foreign 
material  may  be  tolerated  for  a  time,  but  cltolcemia  or  cholestercemia 
is  finally  likely  to  result,  a  poison  being  generated  which  sets  up 
typhoid  symptoms  attended  by  fever  and  succeeded  by  coma,  delirium 
or  convulsions. 

The  diversified  conditions  attending  various  forms  of  hematogen- 
ous  jaundice  will  be  referred  to  under  the  special  diseases  in  which 
they  occur. 

Symptoms. — The  staining  of  the  tissues  is  most  marked  in 
hepatogenous  jaundice.  The  tint  may  vary  from  a  lemon-yellow  to  a 
deep  olive-green  or  bronze,  the  tint  depending  upon  the  permanency 
of  the  obstruction  of  the  biliary  ducts.  As  catarrhal  jaundice  usually 
terminates  within  a  few  days,  the  extreme  depth  of  color  reached  in 
more  serious  obstruction,  as  where  permanent  organic  change  exists, 
does  not  here  occur. 

The  skin  and  conjunctiva  are  markedly  colored,  the  bright-red 
mucus  membrane,  such  as  that  of  the  lips,  tongue  and  buccal  sur- 
faces, not  showing  the  stain  to  auy  great  extent,  though  a  distinct 
yellowness  of  the  hard  palate  may,  in  some  instances,  be  observed. 

Of  the  secretions,  those  most  deeply  colored  are  the  urine  and 
perspiration.  The  color  of  the  urine,  in  which  the  pigment  may  be 
found  before  it  is  apparent  in  the  skin  or  conjunctiva,  may  vary 
from  a  light  greenish-yellow  to  a  deep  black-green.  A  chemical 
test  may  be  made  for  it  bv  placing  a  few  drops  of  the  urine  on  a 
white  porcelain  plate  and  adding  a  drop  or  two  of  nitric  acid,  when, 
if  bile  be  present,  a  rapid  play  of  colors  is  produced,  various  shades 
of  violet,  yellow,  green  and  red  interchanging.  The  urine  colors 
white  linen  yellow,  and  the  perspiration,  especially  in  the  axillae  and 
groins,  may  stain  the  underclothing  a  similar  color.  In  long-stand- 
ing cases  the  urine  may  contain  albumin  and  bile-stained  tube-casts. 
The  tears,  saliva  and  milk  are  not  usually  stained,  although  the 
expectoration  may  be  colored  when  inflammatory  action  in  the  pul- 
monary tissues  exists  along  with  jaundice.  Usually,  however,  the 
sputum  is  not  affected.  Arrest  of  the  usual  flow  of  bile  into  the 
intestine  is  attested  by  clay-colored,  foetid  stools,  constipation  or 
diarrhoea. 


474  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

Pruritis  of  the  skin  is  a  frequent  symptom  of  long-standing 
cases,  and  it  may  be  present  in  brief  catarrhal  jaundice,  though  it  is 
not  apt  to  appear  until  the  condition  has  become  somewhat  pro- 
tracted. Various  eruptions  may  develop  upon  the  skin,  such  as 
boils,  wheals,  lichen  and  urticaria.  Sweating  of  the  abdomen  and 
palms  of  the  hands  is  sometimes  a  persistent  symptom. 

The  pulse  is  often  markedly  reduced  in  frequency  in  obstructive 
jaundice,  the  action  of  the  heart  falling  to  forty,  thirty  and  even 
twenty  pulsations  per  minute.  It  is  not  considered  a  serious  symp- 
tom, however,  being  probably  due  to  temporary  impression  of  the 
biliary  material  upon  the  cardiac  nerves. 

The  effects  of  the  biliary  element  upon  the  nervous  system  are 
variously  manifested.  Drowsiness  is  frequently  present,  jaundiced 
subjects  being  inclined  to  lethargy  and  sleep.  During  waking  hours, 
irritability  and  melancholia  may  be  marked.  Delirium,  coma  or 
convulsions  are  liable  to  develop  suddenly  in  any  case  of  protracted 
jaundice,  and  typhoid  symptoms  frequently  terminate  such  cases. 
Such  cases  are  more  apt  to  attend  hematogenous  than  hepatogenous 
jaundice,  however,  though  long-continued  presence  of  bile  in  the 
blood  in  the  latter  form  is  liable  to  at  length  develop  cholsemia  or 
cholestersemia,  with  grave  symptoms. 

In  hematogenous  jaundice  there  is  not  so  marked  discoloration 
of  the  skin  as  in  obstructive  jaundice,  and  febrile  symptoms  with 
rapid  pulse  are  common.  Bile-pigment  is  not  so  common  in  the 
urine,  though  the  urinary  pigments  may  be  increased,  and  the  stools 
are  not  clay-colored  as  in  the  obstructive  form.  Cerebral  symptoms 
are  more  liable  to  be  marked  here  than  in  hepatogenous  jaundice, 
toxic  forms  being  marked  by  delirium,  coma,  convulsions  and 
speedy  demise. 

The  treatment  of  jaundice,  in  its  various  forms,  will  be  considered 
under  the  different  diseases  giving  rise  to  it.  In  some  cases  treat- 
ment is  effective  and  highly  satisfactory  in  its  results,  while  in 
others,  on  account  of  the  pathological  changes  present,  even  tem- 
porary relief  is  impossible. 

INFANTJLE  JAUNDICE. 

Synonym. — Icterus  Neonatorum. 

Etiology. — The  causes  of  infantile  jaundice  have  already  been 
referred  to.  Reduction  of  blood-pressure  in  the  hepatic  capillaries 
due  to  arrest  of  the  umbilical  circulation  may  prevent  proper  action 
of  the  hepatic  cells  for  a  brief  time,  or  temporary  communication 
between  the  portal  and  general  circulation  may  account  for  mild 
cases  which  recover  spontaneously.  In  the  severe  forms  there  may 


DISEASES  OF  THE  LIVER.  475 

be  congenital  closure  or  absence  of  the  common  bile-duct,  hepatic 
syphilis  of  congenital  form,  or  phlebitis  from  septicaemia  infection 
of  the  remains  of  the  veins  in  the  stump  of  the  umbilical  cord. 

Symptoms. — It  is  frequently  the  case  that  new-born  children 
become  jaundiced  within  the  first  two  or  three  days  of  life  and  in- 
cline to  drowse  continually.  The  skin  presents  a  deep,  yellowish- 
red  color,  instead  of  the  reddish  tint  usually  observed.  The  urine 
stains  the  diapers  yellow  and  the  faeces,  after  the  passage  of  the  me- 
conium,  are  colorless.  The  child  may  nurse,  however,  digest  its 
food  faily  well  and  not  manifest  any  symptoms  of  distress.  The 
well-meaning  but  misinformed  nurse  may  now  administer  a  decoction 
of  saffron  to  "clear  up  the  skin,"  and  in  a  few  days  the  jaundice  dis- 
appears— a  result  which  nature  would  have  accomplished  as  well 
without  the  "saffron  tea"  as  with  it. 

Infantile  jaundice  from  atresia  of  the  bile-ducts  is  a  rare  condi- 
tion, though  several  children  of  the  same  parents  have  been  known 
to  be  similarly  affected.  The  attendant  jaundice  may  not  be  appre- 
ciable to  sight  for  a  week  or  fortnight,  or  even  more.  The  skin,  con- 
junctiva and  hard  palate  become  yellow,  and  the  tint  rapidly  grows 
darker.  The  liver  enlarges,  the  abdomen  becoming  protuberant  and 
distended,  the  swelling  being  largely  due  to  hepatic  and  splenic  con- 
gestion, though  intestinal  gases  and  ascitic  fluid  may  contribute  to 
the  enlargement.  Swelling  of  the  hemorrhoidal  veins  and  bleeding 
from  the  navel  may  attend,  the  latter  symptom  being  especially  no- 
ticeable, often  beginning  soon  after  the  fall  of  the  navel-string  and 
continuing  to  ooze  until  death,  the  discharge  probably  being  due  to 
obstruction  of  the  portal  circulation  from  the  swelling  of  the  liver. 
When  umbilical  hemorrhage  is  combined  with  infantile  jaundice  from 
atresia,  death  follows  within  a  few  days,  though  jaundice  from  con- 
genital atresia  may  otherwise  continue  for  several  months  before  a 
fatal  termination,  the  child  taking  food  well,  but  gradually  wasting 
away,  death  possibly  occurring  finally  from  s.ome  accidental  compli- 
cation, such  as  bronchitis  or  pneumonia. 

Where  infantile  jaundice  is  due  to  syphilitic  inflammation  of  the 
liver,  there  are  such  suggestions  of  syphilis  as  skin  eruptions,  snuf- 
fles, etc.  The  jaundice  appears  at  birth,  the  liver  is  much  enlarged, 
and  there  is  bleeding  from  the  umbilicus  and  bowels,  and  extravasa- 
tion into  the  skin.  Kapid  wasting  and  loss  of  strength  are  followed 
by  subnormal  temperature,  convulsions  and  death. 

When  the  jaundice  is  due  to  umbilical  phlebitis  the  yellow  dis- 
coloration of  the  skin  comes  on  a  few  days  after  birth  and  is  attend- 
ed by  fever,  vomiting  and  complete  loss  of  appetite.  The  child  re- 
fuses the  breast,  appears  piuched  and  haggard,  the  tongue  becomes 
dry,  and  the  hands  and  feet  purple.  The  abdomen  swells  rapidly 


476  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

and  is  tender  upon  pressure,  and  there  is  more  or  less  distinct  fluc- 
tuation, while  blood  and  sanious  pus  ooze  from  the  navel.  The 
jaundice  is  marked,  and  the  urine  may  be  intensely  yellow,  though 
the  stools  may  not  be  affected.  Convulsions  or  coma  may  precede 
death. 

Treatment. — Little  benefit  can  be  expected  from  treatment. 
Iii  mild  infantile  jaundice  minute  doses  of  chionanthiis  may  sometimes 
assist  in  removing  the  coloring  material  from  the  circulation,  though 
probably  a  safer  plan  would  be  to  leave  the  case  to  the  unassisted 
efforts  of  nature.  In  the  jaundice  from  atresia  and  syphilis  nothing 
can  be  expected,  though  echinacea  and  lachesis  may  be  thought  of 
in  umbilical  phlebitis. 

MALTGNANT  JAUNDICE. 

Synonyms. — Icterus  Gravis;  Acute  Yellow  Atrophy  of  the 
Liver. 

Definition. — A  grave  form  of  jaundice  characterized  by  cerebral 
symptoms  and  distinguished  by  extensive  drstruction  of  the  cells  of 
the  liver,  with  the  deposit  of  leucin  and  tyrosin  in  the  urine.  Exten- 
sive necrosis  of  the  liver-cells  is  attended  by  marked  reduction  in 
the  size  of  the  organ. 

Etiology. — This  is  a  rare  disease,  and  one  which  seems  more 
common  in  Europe  than  in  this  country.  The  rapid  and  extensive 
necrosis  which  affects  the  hepatic  cells  suggests  a  powerfully  toxic 
influence  which  can  hardly  be  ascribed  to  any  other  cause  than  that 
of  bacterial  origin.  Pregnant  women  seem  to  be  especially  suscep- 
tible to  it,  as  quite  a  large  proportion  of  those  affected  have  been  of 
this  class,  though  males  are  also  subject.  A  majority  of  cases  occurs 
in  individuals  between  twenty  and  thirty  years  of  age,  though  it  may 
affect  children.  It  is  said  to  have  followed  sudden  fright  or  pro- 
found thought,  excesses  in  venery  and  poor  living. 

Pathology. — The  liver  is  remarkably  reduced  in  size  in  most 
cases,  a  thinning  of  the  organ  being  a  feature.  When  cut  the  sur- 
face is  yellowish-brown  or  reddish-brown,  and  microscopical  exam- 
ination discovers  more  or  less  complete  destruction  of  the  hepatic 
cells  through  the  entire  extent  of  the  organ.  Complete  destruc- 
tion of  the  cells  may  be  discovered  in  some  places,  while  partially 
destroyed  structures  remain  in  others.  Granular  debris,  containing 
pigment  and  crystals  of  leucin  and  tyrosin,  occupy  the  devastated 
sites.  The  capsule  of  the  organ  is  wrinkled,  the  bulk  having 
shrunken  to  a  half  or  a  third  of  its  original  size  and  weight.  Micro- 
organisms have  been  found  in  the  liver-tissues  by  various  observers. 
The  kidneys  are  liable  to  be  involved,  granular  degeneration  of  the 


DISEASES  OF  THE  LIVER  477 

epithelium  occurring.  The  spleen  is  enlarged,  and  the  heart  is  apt 
to  undergo  fatty  degeneration.  Various  organs  are  stained  with  bile 
and  extravasated  with  blood.  The  bile-ducts  and  gall-bladder  are 
empty. 

Symptoms. — The  symptoms  may  not  be  severe  in  the  begin- 
ning, the  condition  resembling  at  first  a  mild  case  of  obstructive 
jaundice  complicated  with  gastro-duodenal  catarrh.  Continuing  in 
this  way  for  from  a  few  days  to  two  or  three  weeks,  a  period  arrives 
at  which  all  the  symptoms  become  suddenly  aggravated.  There  is 
vomiting,  persistent  and  constant;  frequent  hematemesis;  and  hem- 
orrhaghes  may  occur  into  the  skin,  conjunctiva  and  other  parts. 
Nervous  symptoms  are  now  a  marked  feature,  there  being  intense 
headache,  trembling  of  the  muscles,  often  delirium,  and  even  con- 
vulsions. A  marked  increase  of  the  icteric  symptoms  attends  this 
aggravation,  febrile  conditions  are  assumed,  the  temperature  rises, 
the  pulse  becomes  rapid,  and  typhoid  symptoms,  such  as  dryness  of 
the  tongue  with  brown  coating  and  sordes  on  the  teeth  and  lips,  and 
muttering  delirium  or  coma  follow.  However,  pyrexia  is  not  always 
present. 

The  stools  are  clay-colored,  showing  that  no  bile  enters  the  in- 
testine, and  the  urine  contains  bile,  tube-casts,  leucin  and  tyrosin. 

Diagnosis. — Jaundice,  with  delirium  and  diminution  of  the  size 
of  the  liver,  suggests  the  presence  of  this  disease.  Delirium  may 
attend  hypertrophic  cirrhosis,  but  enlargement  of  the  liver  will  there 
serve  to  distinguish  it,  and  febrile  symptoms  are  more  constant. 
Phosphorus  poisoning  may  simulate  this  disease,  as  there  are  jaun- 
dice, hypertrophy  of  the  liver  and  purpura;  but  leucin  and  tyrosin 
are  absent  from  the  urine  and  the  gastric  symptoms  are  more  con- 
stant from  the  start. 

Prognosis. — The  disease  is  usually  fatal  under  old-school  treat- 
ment, and  Eclectics  have  recorded  little  experience  with  it. 

Treatment. — Goss  advises  minute  doses  of  aconite  and  ipecac  to 
control  the  vomiting  and  hsematemesis,  and  chionanthus  and  berberis 
vulgaris  for  the  biliary  symptoms.  Behind  the  symptoms,  however, 
lies  an  important  pathological  change — destruction  of  the  liver-cells 
by  necrosis — which  demands  first  attention.  A  small  group  of  rem- 
edies gives  us  positive  effects  in  many  similar  conditions,  and  may 
be  relied  upon  here  with  good  prospects,  if  begun  early.  This 
group  comprises  such  remedies  as  echinacea,  baptisia  and  lachesis. 
If  the  disease  is  diagnosed  early,  potassium  chloride  3x,  as  usually 
employed,  may  prove  a  serviceable  remedy.  An  easily  digested 
liquid  diet  should  be  adhered  to,  such  articles  as  peptonized  milk, 
meat  broths,  buttermilk,  clam  broth  and  Horlick's  malted  milk  con- 
stituting its  basis. 


478  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

ABNORMALITIES  OF  THE  HEPATIC  CIRCULATION. 

ACTIVE  HYPEB^MIA. — This  may  follow  meals  as  a  physiological 
act,  the  rapid  absorption  of  the  portal  vessels  resulting  in  vascular 
fullness  of  the  liver.  When  overeating  is  habitually  indulged  in,  a 
condition  of  chronic  hyperaemia  may  finally  follow,  with  functional 
disturbance;  and  when  alcohol  is  indulged  in  to  large  extent  cir- 
rhotic  changes  may  arise.  The  principal  symptom  is  a  sense  of  full- 
ness in  the  right  hypochondriac  region,  with  dypsnoea  dependent 
upon  difficulty  in  drawing  the  diaphragm  downward,  this  passing  off 
after  time  of  digestion  has  gone  by.  Regulation  of  the  diet  is  obvi- 
ously the  most  important  part  of  treatment,  though  aploppapus  larici- 
folius  will  afford  temporary  relief  (saturated  tincture,  gtt.  v-x,  in  a 
swallow  of  water  at  a  single  dose). 

PASSIVE  CONGESTION. — This  involves  the  sublobular  branches  of 
the  hepatic  veins,  and  is  due  to  backward  pressure  from  the  general 
circulation.  Obstruction  in  the  right  heart  or  lungs,  and  tricuspid 
insufficiency  may  be  causes — any  condition  attended  by  venous  sta- 
sis in  the  right  side  of  the  heart,  emphysema,  pulmonary  cirrhosis, 
intrathoracic  tumors  or  chronic  valvular  disease  being  prominent 
among  the  clinical  causes.  Chronic  pressure  from  cardiac  impact 
may  give  rise  to  gradual  dilatation  of  the  sub-lobular  and  intra-lobu- 
lar  vessels,  the  intra-lobular  capillaries  compressing  the  hepatic  cells 
until  they  may  finally  become  atrophied,  a  cut  section  of  the  organ 
presenting  a  mottled  appearance  due  to  the  large  amount  of  venous 
blood  in  the  central  capillaries,  deposit  of  pigment  and  augmen- 
tation of  connective  tissue;  the  condition  being  termed  "nutmeg 
liver."  Among  the  symptoms  may  be  pulsation  of  the  liver  due  to 
impact  from  the  cardiac  systole,  gastro-intestinal  catarrh,  with  oc- 
casional hsematemesis.  Ascites  may  finally  appear  as  a  result  of 
obstruction  to  the  portal  circulation,  and  icteric  staining  of  the  skin 
attends,  with  bile-pigment  in  the  urine  and  clay-colored  stools.  The 
liver  is  appreciably  enlarged,  the  organ  being  crowded  downward 
and  rolling  outward  beneath  the  ribs,  imparting,  upon  palpation, 
a  sensation  of  firmness  to  pressure. 

Treatment  is  not  very  satisfactory,  as  the  disease  is  secondary, 
usually,  to  organic  change  of  the  heart  or  lungs,  and  a  cure  must 
depend  upon  a  removal  of  the  exciting  cause.  To  lessen  pressure  in 
the  portal  vein,  such  remedies  as  carduus  marianus,  polymnia,  ceano- 
thus  and  grindelia  squarrosa  should  be  thought  of.  Aploppapus  larici- 
foliiis  is  an  excellent  remedy  in  some  cases  for  this  purpose.  The 
withdrawal  of  fifteen  or  twenty  ounces  of  blood  from  the  liver  by 
aspiration  has  been  recommended,  but  the  result  must  necessarily 
be  temporary,  and  would  hardly,  it  seems,  justify  such  a  procedure. 


DISEASES  OF  THE  LIVER.  479 

Depletion  of  the  portal  circulation  might  be  brought  about  by  the 
free  administration  of  hydragogue  cathartics,  though  the  gastro- 
intestinal catarrh  would  contraindicate  the  use  of  irritants  here,  the 
salines  being  more  appropriate.  Attention  must  be  paid  to  the  con- 
dition of  the  pulmonary  and  cardiac  circulation,  appropriate  reme- 
dies being  directed  to  abnormal  states  in  these  parts. 

DISEASES  OF  THE  PORTAL  VEIN. — Chronic  portal  obstruction  may 
arise  from  chronic  congestion  of  the  liver,  the  etiology  of  which 
has  already  been  considered.  Local  causes  are  cirrhosis,  pressure 
from  tumors  involving  the  liver  or  located  in  the  vicinity  of  the 
portal  vein,  compression  from  proliferative  peritonitis,  or  from 
thrombosis. 

Thrombosis  or  adhesive  pylephlebids  of  the  portal  vein  occurs  second- 
arily, from  pressure  upon  the  portal  vein  or  one  of  its  branches  from 
tumors,  perforation  of  the  vein  by  gall-stone  or  invasion  by  cancer. 
When  it  occurs  primarily  it  is  during  moribund  processes,  and  is 
not  of  importance.  When  occurring  secondarily,  the  clot  becomes 
organized,  grows  pale  and  firm,  and  may  finally  become  converted 
into  connective  tissue.  It  may  become  perforated  and  permit  of  the 
passage  of  a  limited  quantity  of  blood,  a  permanent  narrowing  re- 
maining and  modifying  the  attending  symptoms. 

The  symptoms  are  announced  by  vomiting  with  diarrhoea,  usually 
attended  by  haematemesis  and  enterorrhagia.  Dilatation  of  the  por- 
tal vein  behind  the  point  of  obstruction  rapidly  follows,  with  rapidly 
accumulating  ascites.  Dyspnoea,  anorexia,  prostration  and  heart 
failure  result,  a  fatal  termination  usually  following  within  a  week  or 
ten  days.  When  some  small  branch  only  is  involved,  a  collateral 
circulation  may  be  established  and  the  patient  may  live  for  years, 
though  in  indifferent  health,  general  emaciation  and  prostration  with 
occasional  gastric  or  intestinal  hemorrhage  attending.  The  diagno- 
sis is  difficult,  and  the  prognosis  is  exceedingly  bad.  Treatment  is  un- 
satisfactory, temporary  relief,  in  all  cases  in  which  collateral  cir- 
culation is  not  established,  being  all  that  can  be  expected.  The 
ascitic  accumulation  should  be  removed  by  paracentsis,  and  the  diet 
sliouM  be  sparing.  Diuretics  and  cathartics  are  recommended,  but 
cathartics  would  be  liable  to  provoke  more  discomfort  than  they 
would  assuage.  Restriction  of  the  diet  to  almost  a  point  of  starva- 
tion would  be  the  most  rational  measure  to  pursue. 

Septic  thrombosis  or  suppurative  pylephlebitis  of  the  portal  vein 
is  characterized  by  the  formation  of  a  thrombus  in  the  portal  vein 
with  subsequent  breaking  down,  from  the  presence  of  infective  ma- 
terial. In  this  case  the  thrombus  is  not  due  to  pressure,  but  arises 
from  localized  inflammation  of  the  vein,  caused  by  intestinal  ulcera- 
tion,  abdominal  abscess,  or  such  penetrating  bodies  as  spiculae  of 


480  DISEASES  OF    THE  DIGESTIVE  ORGANS. 

bone,  pins,  needles,  tacks,  etc.,  which  have  been  accidentally  swal- 
lowed and  which  penetrate  the  intestine,  and  later  the  portal  vein. 
In  infants  septic  material  may  enter  from  the  way  of  the  navel,  and 
give  rise  to  similar  conditions.  A  clot  forms  at  the  point  of  pene- 
tration, to  afterward  break  down  from  suppurative  action.  Emboli 
may  be  distributed  to  the  liver  from  here,  septic  abscesses  be  scat- 
tered through  its  substance,  and  even  general  pyaemia  may  attend, 
the  emboli  sometimes  passing  the  lobular  circulation.  Symptoms  of 
portal  obstruction,  septicaemia,  pyaemia,  and  multiple  abscesses  of 
the  liver  occur.  Fatal  results  invariably  attend  within  ten  days  or 
two  weeks,  and  treatment  can  be  palliative  only. 

Affections  of  the  hepatic  vein  are  rare,  its  peculiar  structure  serving 
to  protect  it  greatly  against  infection  or  embolusfrom  the  abdominal 
circulation.  Enlargement  of  the  right  heart  results  in  its  dilatation, 
and  stenosis  may  arise  at  the  orifices  of  its  branches,  general  en- 
largement and  induration  of  the  liver  being  the  result. 

Dilatation  of  the  hepatic  artery  may  attend  cirrhosis  of  the  liver, 
and  it  may  be  sclerosed,  or  be  the  seat  of  aneurism. 

INTERSTITIAL  HEPATITIS. 

Synonyms. — Cirrhosis  of  the  Liver;  Sclerosis  of  the  Liver; 
Gin-drinker's  Liver;  Hob-nailed  Liver.  The  term  "cirrhosis"  was 
applied  by  Laennec,  on  account  of  the  yellow  color  of  the  diseased 
organ. 

Definition. — An  inflammation  of  the  connective-tissue  of  the 
liver,  attended  by  strangulation  of  the  hepatic  circulation,  and  conse- 
quent destruction  of  the  hepatic  cells. 

Etiology. — Influences  which  originate  and  perpetuate  irritation 
of  the  capillaries  of  the  hepatic  circulation  predispose  to  this  condi- 
tion. The  most  common  is  probably  alcoholic  addiction,  the  habit 
of  taking  spirituous  liquors  on  an  empty  stomach  being  especially 
liable  to  produce  it,  as  the  stimulating  influence  of  the  alcohol  on  the 
hepatic  circulation  is  then  most  pronounced.  Highly  seasoned  food 
containing  stimulating  condiments  is  liable  to  result  in  a  similar  con- 
dition, when  indulged  in  for  a  long  time.  The  acute  infectious  dis- 
eases, notably  scarlet  fever,  may  inaugurate  interstitial  hepatitis. 
Gout,  syphilis  and  rheumatism  may  be  included  among  the  pre- 
disposing causes.  Malaria,  by  producing  continued  engorgement  of 
the  portal  circulation,  is  not  an  infrequent  cause.  Cardiac  and  pul- 
monary obstruction  may  be  attended  by  sufficient  backward  hepatic 
impact  to  result  in  final  cirrhosis.  It  often  attends  tuberculosis  of 
the  liver.  Anthracosis  of  the  Irver  is  said  to  be  a  cause  among  min- 
ers and  workers  in  coal. 


DISEASES  OF  THE  LIVER.  481 

Pathology. — The  coimective  tissue  surrounding  the  smaller  twigs 
of  the  portal  vein  is  usually  first  involved,  the  inflammation  gradu- 
ally extending  to  the  larger  branches.  The  rapid  proliferation  of 
embryonic  cells  results  at  first  in  a  soft,  reddened,  pulpy  mass,  which 
distends  the  portal  canals  and  increases  the  volume  of  the  entire 
liver.  As  the  new  cells  undergo  organization  into  permanent  fibrous 
material  contraction  follows,  and  compression  is  exerted  upon  the 
portal,  interlobular  and  central  vessels,  arresting  their  functions. 
Nutrition  of  the  lobules  is  thus  cut  off,  and  the  pressure  exerted  en- 
croaches upon  the  hepatic  cells,  aiding  in  causing  atropy  and  degen- 
eration of  their  structure.  The  outer  cells  of  the  lobules  undergo 
fatty  degeneration  at  first,  though  complete  obliteration  of  the  lobules 
may  follow,  their  places  being  filled,  in  some  instances,  with  newly- 
formed  connective  tissue.  The  cells  surrounding  the  central  vein 
are  degenerated,  atrophic  and  deeply  stained  with  bile.  The  portal 
canals  present,  upon  the  surface  of  the  liver,  depressions  from  con- 
traction of  fibrous  tissue,  the  intervening  lobules  imparting  a  granu- 
lated impression,  and,  as  the  contraction  proceeds,  the  entire  organ 
may  become  corrugated  and  nodular  upon  the  surface,  affording 
the  condition  known  as  hob-nailed. 

If  a  section  of  the  organ  be  made  during  the  early  stage  of  the 
disease,  the  cut  surface  presents  a  hypersemic,  pulpy  appearance  and 
the  entire  organ  is  enlarged;  but  in  a  later  stage  the  tissues  are  firm 
and  fibrous,  cut  with  resistance,  and  the  section  presents  a  mottled, 
yellow  surface,  upon  which  may  be  seen  yellow  spots  stained  with 
bile-pigment,  representing  the  central  portions  of  lobules  surrounded 
by  lighter  colored  zones  of  fatty  degeneration,  with  surrounding 
areas  of  slaty-gray,  fibrous  material.  The  smaller  portal  vessels  are 
shrunken,  convoluted  and  twisted,  and  their  lumen  may  be  complete- 
ly obstructed,  new  channels  sometimes  being  formed  between  the 
portal  and  hepatic  veins.  Separate  branches  from  the  hepatic  artery 
are  sometimes  traceable  in  the  newly-formed  connective  tissue,  and 
the  main  artery  is  dilated  and  tortuous. 

In  hypertrophic  (fatty)  cirrhosis,  the  new  connective  tissue  in- 
sinuates itself  about  the  bile-ducts  and  within  the  lobules,  imparting 
a  firmness  which  occurs  coincidentally  with  the  development  of  con- 
nective tissue  in  the  portal  channels,  and  resists  contraction,  the  vol- 
ume of  the  organ  being  permanently  augmented  by  the  growth  of 
connective  tissue  in  its  minute  structure  and  the  deposition  of  fat  in 
the  parenchyma  of  the  lobules.  Another  form  of  hypertrophic  cir- 
rhosis (biliary  cirrhosis)  is  marked  by  early  obstruction  of  the  small 
biliary-ducts  and  their  radicles,  these  becoming  permanently  dis- 
tended and  infiltrated  with  bile-pigment.  Coincidently  with  this 
there  is  an  abundant  development  of  new  connective  tissue,  but  the 


482  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

biliary  engorgement  offers  an  obstacle  to  contraction,  and  the  organ 
not  only  retains  its  size  but  becomes  augmented  in  bulk. 

Syphilitic  cirrhosis  may  result  in  atrophy  or  hypertrophy  of  the 
liver.  When  the  capsule  is  largely  involved,  contraction  of  the 
organ  results,  and  it  may  be  diminished  in  size,  the  general  ana- 
tomical condition  resembling  that  of  cirrhosis  from  other  causes.  In 
diffuse  syphilitic  hepatitis  there  may  be  permanent  enlargement 
of  the  organ,  large  bands  of  puckered  fibrous  tissue,  visible  to  the 
naked  eye,  appearing  in  isolated  patches,  and  gummata  being  more 
or  less  numerous,  scattered  through  the  substance,  the  fresh  gum- 
mata presenting  a  reddish-gray,  translucent  appearance,  and  the 
older  ones  being  surrounded  by  connective- tissue  capsules,  their 
centers  being  broken  down  into  puriform  material  or  transformed 
into  fibrous,  cheesy  or  calcerous  masses. 

Anatomically,  four  forms  of  hepatic  cirrhosis  have  been  recog- 
nized: (1)  The  atrophic  cirrhosis  of  Laennec;  (2)  perihepatitis  or 
Glissonian  cirrhosis;  (3)  fatty  cirrhosis;  and  (4)  hypertrophic  cir- 
rhosis. Two  of  these  forms,  viz.,  the  atrophic  cirrhosis  of  Laennec 
and  Glissonian  cirrhosis,  are  attended  by  final  atrophy,  and  two, 
fatty  cirrhosis  and  hypertrophic  cirrhosis,  are  attended  by  permanent 
enlargement. 

In  the  atrophic  cirrhosis  oj  Laennec  the  liver,  in  advanced  stages, 
is  very  much  diminished  in  size,  and  its  tissues  are  remarkably  firm 
and  resistant  to  the  knife  when  cut.  Its  outer  surface  is  granulated, 
the  contraction  which  it  has  undergone  may  have  resulted  in  deform- 
ity of  shape,  and  its  weight  may  be  reduced  to  a  third  or  a  fourth 
of  its  normal  amount.  When  the  cut  surface  is  examined  critically, 
it  will  be  seen  to  present  isolated,  greenish-yellow  spots,  surrounded 
by  grayish-white  fibrous  tissue* 

In  Glissonian  cirrhosis  there  is  remarkable  development  and 
fibrous  degeneration  of  Glisson's  capsule,  due  to  localized  peritonitis 
involving  the  perihepatic  membrane.  The  capsule  is  hardened, 
almost  cartilaginous  in  consistency,  and  adhered  to  surrounding  or- 
gans. Sometimes  the  hepatic  tissue  underneath  it  may  appear  unal- 
tered, though  it  is  compressed,  the  bulk  of  the  entire  organ  shrunken, 
and  there  is  usually  extensive  destruction  of  the  lobules.  Some- 
times the  fibrous  growth  occurs  most  extensively  in  the  interior 
of  the  organ,  its  prolongations  along  the  portal  canals  being  princi- 
pally involved.  Perihepatitis  is  common  in  syphilitic  cirrhosis,  the 
capsule  being  thickened  and  adherent  to  surrounding  organs,  while 
fibrous  bands  pass  into  the  substance  of  the  liver,  undergoing  con- 
traction, causing  deformity  and  resulting  in  fibrous  scars.  These 
scars  represent  the  sites  of  gummatous  deposite,  these  being  most 
numerous  along  the  attachment  of  the  suspensory  ligament. 


DISEASES  OF  THE  LIVER.  483 

Infatty  cirrhosis  the  size  of  the  liver  is  permanently  increased, 
the  surface  presenting  a  smooth  or  slightly  granular  condition  with 
yellowish-white  or  anaemic  hue,  the  general  appearance  being  that  of 
a  fatty  liver,  though  when  cut  its  resistance  to  the  knife  determines 
the  difference,  evincing  the  presence  of  a  large  amount  of  fibrous  tis- 
sue. The  excessive  amount  of  fat  deposited  in  the  lobules  accounts 
for  its  bulky  appearance,  though  this  is  not  a  distinctive  feature 
as  fatty  degeneration  occurs  in  the  peripheral  zone  of  the  lobules 
in  all  forms  of  cirrhosis. 

Hypertrophic  cirrhosis  proper,  or  biliary  cirrhosis,  is  characterized 
by  the  retention  of  bile  in  the  small  biliary  passages  and  their  radi- 
cles, with  infiltration  of  pigment  into  the  lobules  and  connective  tis- 
tue.  Fibrous  deposits  in  the  lobular  capillaries  impart  an  early 
firmness  which  resists  contraction  and  results  in  permanent  enlarge- 
ment, and  pigmentation  imparts  a  deep-brown  or  black  color  to  the 
affected  tissues.  The  obstruction  to  the  portal  circulation  gives  rise 
to  numerous  pathological  conditions  about  the  tissues  drained  by  its 
radicles.  Without  an  extensive  collateral  circulation  speedily  fatal 
results  must  soon  follow.  In  spite  of  this,  engorgement  of  the  gas- 
tro-intestinal  radicles  results  in  catarrh  of  the  stomach  and  bowels, 
exudation  of  blood  into  the  alimentary  canal  signalized  by  haemate- 
mesis  and  melsena,  and  effusion  of  serum  into  the  peritoneal  cavity 
(ascites). 

Such  changes  however,  are  modified  by  collateral  venous  con- 
nection between  the  general  and  portal  venous  systems,  this  some- 
times being  very  extensive  an^d  at  other  times  very  restricted.  The 
hemorrhoidal  plexus  communicates  with  radicles  of  the  portal  sys- 
tem and  of  the  internal  iliac,  through  which  the  surcharged  portal 
vessels  may  find  some  relief.  The  left  renal  vein  anastomoses  with 
the  radicles  of  the  duodenum  and  colon.  The  phrenic  vein  may 
anastomose  with  superficial  branches  of  the  portal  vein.  New  chan- 
nels are  sometimes  formed  within  the  liver,  between  the  portal  and 
hepatic  veins.  Adhesions  which  may  form  between  the  liver  and 
other  organs  may  develop  branches  of  sufficient  size  to  convey  con- 
siderable of  the  obstructed  blood.  A  venae  comites  of  the  obliter- 
ated umbilical  vein  may  become  dilated  and  accompany  the  round 
ligament  to  the  umbilicus,  and  this  may  anastomose  with  the  inter- 
nal mammary  and  epigastric  veins.  When  this  anastomosis  is  well 
marked,  a  circle  of  dilated  veins  (caput  Medusae)  is  to  be  observed 
around  the  umbilicus.  Other  branches  accompany  the  suspensory 
ligament  and  become  enlarged,  anastomosing  with  the  diaphragmatic 
veins,  and  thus  joining  the  azygous  veins.  The  oesophageal  and  gas- 
tric venous  radicles  also  anastomose,  thus  affording  an  additional 
channel  for  the  escape  of  the  obstructed  portal  circulation. 


484  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

Symptoms. — The  extent  of  the  collateral  circulation  will  deter- 
tine,  to  considerable  degree,  the  severity  of  the  symptoms.  When 
this  is  extensive,  a  subject  of  hepatic  cirrhosis  may  not  suffer 
marked  disturbance,  and  may  continue  in  comparative  comfort  for  a 
long  time.  However,  this  is  not  usually  the  case.  Hepatic  con- 
gestion is  soon  announced  by  sensation  of  fullness  and  weight  in  the 
right  hypochondrium  with  dypsnoea,  from  crowding  beneath  the  dia- 
phragm; the  hepatic  region  is  protuberant,  tender  upon  pressure, 
and  the  area  of  dullness  about  the  liver  is  increased,  while  pal- 
pation may  detect  the  hard  edge  of  the  organ  a  hand's  breadth  below 
the  ribs.  General  malaise,  with  headache,  anorexia,  nausea,  furred 
tongue,  and  disgust  for  meats,  soon  attends.  Gastric  irritation  now 
develops,  the  patient  being  attacked  with  retching  and  empty  vomit- 
ing, especially  in  the  morning  upon  waking  from  slumber,  varying 
attacks  of  diarrhoea  being  interspersed.  The  digestion  of  food  is 
soon  attended  by  all  the  distress  of  gastric  catarrh,  and  the  tongue 
may  become  red  and  pointed.  The  countenance  assumes  a  muddy, 
icteric  hue  (though  not  a  markedly  jaundiced  one),  the  skin  becomes 
dry  and  harsh,  the  spleen  enlarged,  hemorrhoids  appear,  and  a  caput 
Medusae,  with  enlargement  of  the  superficial  abdominal  veins,  may 
be  observed.  Emaciation  and  cachexia  rapidly  encroach,  and  the 
patient  may  be  subject  to  vertigo,  prostration,  and  occasional  pangs 
of  acute  pain  in  the  right  hypochondrium  due  to  intercurrent  attacks 
of  perihepatitis. 

As  the  disease  continues,  hsematemesis  and  melaena  occasionally 
occur,  and  the  gastric  symptoms  become  still  more  aggravated. 
Palpation  of  the  right  hypochondriac  region  may  now  enable  one  to 
detect  a  lessening  in  the  size  of  the  liver,  a  sense  of  hardness  and 
irregularity  of  the  surface  being  imparted  to  the  touch.  Tympanites 
of  the  abdomen  appears,  and  ascites  follows  at  a  later  stage,  while 
oedema  of  the  feet  and  ankles,  and,  finally,  general  anasarca,  may  be 
developed.  Jaundice  is  not  a  marked  symptom  except  in  biliary 
cirrhosis,  as,  though  there  is  obstruction  to  the  secretion  of  bile,  the 
ducts  remain  open  for  its  discharge  into  the  intestine.  The  mind 
usually  remains  clear  to  the  last,  though  delirium  or  coma  may  at- 
tend the  closing  scene. 

The  symptoms  of  biliary  cirrhosis  are  distinctive.  The  hypo- 
chondric  fullness  is  marked,  and  jaundice  is  an  early  feature. 
(Edema  of  the  face  and  limbs,  profuse  sweats,  hemorrhages,  with  in- 
creasing jaundice,  though  without  marked  emaciation,  attend.  Ascites 
is  not  so  common  as  in  the  atrophic  forms,  and  the  hepatic  enlarge- 
ment is  progressive,  the  enlarged  liver  being  smooth  and  rounded. 
Enlargement  of  the  spleen  is  noticeable.  After  a  time  fhe  disease 
is  likely  to  terminate  with  symptoms  of  acute  febrile  jaundice,  a 


DISEASES  OF  THE  LIVER.  485 

cliill  ushering  in  febrile  symptoms,  with  delirium,  coma,  convulsions, 
and  death.  The  disease  may  exist  in  the  chronic  form  for  two  years 
or  more,  the  acute  termination  lasting  ten  days  or  two  weeks. 

Diagnosis. — The  former  habits  of  the  patient  will  aid  in  a 
diagnosis.  An  individual  addicted  to  alcohol  who  suffers  with 
hepatic  enlargement,  gastric  disturbance,  hemorrhages  from  the 
stomach  and  bowels  aud  ascites,  is  probably  a  subject  of  cirrhosis. 
The  firm,  hard  or  nodulated  liver,  felt  upon  palpation  during  the 
second  stage,  with  evident  contraction  of  bulk,  is  a  strong  suggestion 
of  the  disease.  Palpation  should  here  be  made  after  paracentesis, 
in  order  to  examine  the  organ  carefully.  Enlargement  of  the  spleen 
existing  coincidentally,  is  additional  evidence  of  cirrhosis.  A  his- 
tory of  syphilis  with  the  preceding  developments  may  be  considered 
confirmatory  of  a  suspicion  of  cirrhosis,  and  young  children  with 
syphilitic  antecedents  are  liable  to  it.  Cancer  of  the  liver  will  be 
differentiated  by  the  marked  cancer  cachexia  and  rapid  loss  of 
strength,  which  is  more  evident  than  in  cirrhosis.  Obstruction  of 
the  portal  vein  by  fibrous  thrombosis  may  be  difficult  to  distinguish 
from  cirrhosis,  as  the  symptoms  are  very  similar.  The  enlargement 
which  attends  the  early  stage  may  be  difficult  to  distinguish  from 
fatty  liver,  though  there  is  absence  of  pain  and  gastric  com- 
plication. 

Prognosis. — The  prognosis  is  usually  unfavorable,  though 
where  there  is  extraordinary  collateral  circulation  the  subject  may 
survive  for  years.  However,  hepatic  cirrhosis  terminates  fatally 
within  a  few  years  in  most  cases,  and  it  may  run  its  course  in  a  few 
mouths.  After  ascites  and  hematemesis  appear  there  is  little  hope 
of  a  favorable  termination,  though  if  the  disease  be  diagnosed  early 
and  proper  treatment  be  employed  there  is  considerable  probability 
of  improvement. 

Treatment. — All  exciting  causes  should  be  avoided.  Alcoholic 
liquors  must  not  be  allowed  under  any  circumstances,  and  stimulat- 
ing and  highly  seasoned  food  should  be  forbidden.  The  most  bland 
and  uuirritating  food  should  be  chosen,  a  milk  diet  with  crackers 
and  stale  bread  being  preferable.  To  relieve  gastric  disturbances, 
plenty  of  hot  water  should  be  taken,  aerated  waters  being  benefi- 
cial. A  careful  study  of  some  reliable  work  on  diet  will  be  useful 
to  the  patient,  that  he  may  possess  an  intelligent  idea  of  what  is 
best  suited  to  his  case.  Sometimes  milk  causes  "biliousness,"  and 
other  footl  may  be  required,  buttermilk,  koumiss,  whey,  or  malted 
milk  being  preferable.  After  ascites  has  appeared  fluids  had  better 
be  dispensed  with,  as  they  tend  to  increase  the  amount  of  dropsical 
accumulation.  A  dry  diet,  consisting  of  stale  bread  with  a  small 
quantity  of  meat,  such  as  the  white  flesh  of  fish,  oysters,  sweetbread, 


486  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

liver,  roast  or  broiled  beef,  and  eggs,  may  be  consumed,  in  limited 
quantities.  Tea  and  coffee  should  be  avoided.  Certain  vegetables, 
such  as  radishes,  onions,  garlic,  etc.,  stimulate  the  liver;  though 
others,  as  spinach,  asparagus,  tomato,  squash,  pumpkin,  celery,  let- 
tuce, oyster  plant,  etc.,  are  allowable.  Fruits  are  commendable  to 
encourage  normal  evacuation,  though  they  should  be  selected  with 
a  view  of  avoiding  a  stimulating  influence  upon  the  liver.  Straw- 
berries, grapes,  oranges,  apples,  and  peaches  may  be  eaten.  The 
same  precaution  should  be  taken  as  in  gastric  catarrh;  the  food 
should  be  taken  slowly  and  thoroughly  masticated,  and  its  amount 
should  be  limited  to  only  enough  to  supply  the  needs  of  the  body, 
it  being  better  for  the  meals  to  be  taken  alone. 

When  treatment  is  begun  at  an  early  stage  of  the  disease,  while 
the  liver  is  hypersemic,  much  benefit  will  follow  the  use  of  potassium 
chloride  3x,  five  grains  in  half  a  glass  of  water,  dose,  a  teaspoonful 
every  two  hours,  while  awake.  This  will  effectually  prevent  the 
organization  of  the  newly-formed  plastic  material,  and  tend  to  per- 
manent recovery.  After  the  advanced  stage  has  been  reached,  med- 
ication is  of  little  use  except  to  temporarily  relieve  aggravated 
symptoms. 

Gastric  fermentation  may  be  temporarily  relieved  by  lavage  or 
by  the  use  of  hydrozone,  and  nausea  and  vomiting  may  be  treated 
with  minute  doses  of  aconite  and  rhus  tox.  When  ascites  becomes 
so  extreme  as  to  cause  much  discomfort,  paracentesis  abdominalis 
should  be  resorted  to,  and  this  should  be  repeated  sufficiently  often 
to  prevent  unpleasant  crowding  of  the  abdominal  cavity.  Chioiian- 
thus  and  chelidonium  may  afford  some  benefit  in  biliary  cirrhosis. 
Syphilitic  cirrhosis  should  be  treated  with  iodide  of  potassium. 
Protonuclein  may  be  found  of  service  here,  administered  early. 

ABSCESS  OF  THE  LIVER. 

Synonym. — Suppurative  Hepatitis. 

Etiology. — Abscess  of  the  liver  occurs  as  a  single,  large  accu- 
mulation of  pus  in  one  lobe  of  the  organ,  or  as  numerous  small,  sep- 
arate accumulations  of  purulent  material,  scattered  throughout  the 
liver-tissue. 

Large  or  single  abscess  of  the  liver  occurs  most  frequently  in 
tropical  regions,  either  idiopathically  or  as  a  sequel  to  dysentery, 
and  the  fact  that  the  amoeba  coli  is  invariably  found  in  the  pus  in 
such  cases  points  strongly  to  its  influence  as  an  etiological  factor. 
It  is  a  common  disease  in  India,  especially  among  Europeans  who 
indulge  freely  in  the  use  of  alcoholic  drinks,  and  is  not  rare  in  the 
southern  states  of  our  own  country.  Large  single  abscesses  of  the 


DISEASES  OF  THE  LIVER.  487 

liver  may  result  from  traumatism,  blows  received  about  the  middle 
of  the  body  and  falling  upon  the  organ  frequently  result  in  sup- 
puration. Pugilists  and  railroad  brakemen  are  most  liable  to  suffer 
from  this  form,  the  crushing  effect  of  injuries  received  while  coup- 
ling cars  rendering  the  vocation  of  brakeman  especially  hazardous 
in  this  respect.  It  is  extremely  rare  among  women,  not  more  than 
four  or  five  per  cent,  of  all  cases  occurring  in  females. 

Multiple  abscess  of  the  liver  is  usually  due  to  dissemination  of 
purulent  material  along  the  portal  canals  from  infection  of  the  por- 
tal blood  outside  of  the  liver,  though  the  suppuration  is  sometimes 
due  to  irritation  of  the  bile-passages  from  gall-stones  (suppurative 
cholangitis);  parasites  in  the  liver,  such  as  the  echinococcus,  intes- 
tinal worms,  or  the  fluke-worm;  tuberculosis  of  the  liver;  or  pene- 
tration of  its  substance  by  such  foreign  body  as  a  needle  or  fish- 
bone, which  has  perforated  the  oesophagus  and  wandered  into  the 
hepatic  tissues. 

Embolic  or  pycemic  abscesses  of  the  liver  may  develop  from  gen- 
eral pyaemia,  the  infection  entering  through  the  hepatic  artery  ;  or  it 
may  arise  from  causes  originating  among  the  radicles  of  the  portal 
vein  or  in  the  vein  itself,  when  suppurative  thrombosis  of  that  ves- 
sel occurs.  The  ulceration  of  typhoid  fever  may  afford  a  nidus  from 
which  infective  material  may  enter  the  portal  vein  and  reach  the 
liver.  Dysentery,  rectal  disease,  appendicitis,  or  pelvic  abscess 
may  furnish  the  element  of  multiple  suppuration  of  the  liver,  the 
ramifications  of  the  portal  vein  distributing  it  throughout  the  organ. 
In  new-born  children  the  infection  may  enter  through  the  umbilicus. 

Pathology. — In  single  abscess  of  the  liver  the  right  lobe  is  the 
usual  seat  of  suppuration,  an  extensive  area  of  destruction  being 
involved.  Sometimes  several  quarts  of  pus  may  be  discharged  from 
an  abscess  of  this  character  at  one  time.  Instead  of  a  single  abscess, 
two  or  more  large  ones  may  exist,  these  either  remaining  single  or, 
as  the  disease  progresses,  coalescing.  The  pus  may  be  limited  by 
an  abscess- wall  or  not,  there  frequently  being  no  limiting  membrane, 
the  confines  being  irregular  projections  of  semi-disorganized  liver- 
tissue,  projecting  into  the  abscess-cavity.  The  purulent  material 
varies  according  to  the  origin  of  the  disease,  that  of  tropical  abscess 
being  of  a  reddish-brown  color,  resembling  anchovy  sauce,  pos- 
sessing a  peculiar  odor  resembling  that  of  chyme,  and  containing 
amoebae  coli  in  great  numbers.  In  traumatic  cases,  the  pus  may  be 
flocculeut  and  thin,  or  thick,  creamy,  and  yellowish-green  or  brick- 
red  in  color,  from  the  staining  of  bile  or  bilirubiu.  In  traumatic 
abscess  the  pus  is  sterile  of  microorganisms. 

As  the  disease  continues,  the  pus  gradually  works  its  way  toward 
the  surface  of  the  liver  and  finally  perforates  the  limiting  structures, 


488  DISEASES  OP  THE  DIGESTIVE  ORGANS. 

sometimes  opening  into  the  pleural  cavity,  sometimes  perforating 
the  diaphragm  and  discharging  through  the  lung,  sometimes  pene- 
trating the  pericardium,  vena  cava,  intestine,  stomach,  kidney,  gall- 
bladder, or  peritoneal  sac.  Adhesion  of  the  peritoneal  surfaces  may 
occur,  and  the  pus  burrow  its  way  to  the  surface  through  the 
abdominal  or  thoracic  wall.  Nine  per  cent  of  all  cases  discharge 
through  the  right  lung,  and  five  per  cent  empty  into  the  right  pleura. 
With  modern  surgical  knowledge,  spontaneous  discharge  of  pus  will 
be  anticipated,  in  these  cases,  by  early  evacuation. 

Multiple  abscesses  arising  from  pylephlebitis  are  distributed  to  the 
ramifications  of  the  portal  vein,  the  abscesses  usually  lying  near  the 
capsule.  Numerous  white  points  frequently  appear  beneath  the  cap- 
sule, marking  the  locations  of  purulent  deposits,  and  if  these  be 
traced  by  probing  they  are  found  to  communicate  with  the  portal 
veins.  The  liver,  especially  the  right  lobe,  is  markedly  enlarged, 
the  organ  rising  into  the  thorax  and  extending  as  much  as  a  hand's 
breadth  below  the  margin  of  the  ribs.  The  suppuration  may  extend 
along  the  branches  of  the  portal  vein,  even  into  the  main  branch, 
and  thrombi  may  be  distributed  to  its  branches,  in  various  parts  of 
the  liver.  In  obstruction  by  gall-stones,  the  biliary  ducts  and  gall- 
bladder may  be  filled  with  purulent  material.  The  pus  is  foetid, 
greenish-yellow,  and  it  may  be  flocculent,  though  it  is  frequently 
thick  and  laudable.  Large  abscesses  may  form  about  hydatid  cysts, 
the  presence  of  echinococci  indicating  their  morbid  character. 

Symptoms. — In  rare  cases,  tropical  abscess  may  arise  insid- 
iously and  rupture  without  warning,  sudden  death  occurring  from  an 
unsuspected  cause.  Usually,  however,  the  onset  of  the  disease  will 
be  announced  by  chills,  following  a  short  period  of  malaise,  during 
which  the  temperature  may  be  subnormal.  The  chills  may  occur 
periodically,  and  be  followed  by  paroxysms  of  fever  which  decline 
by  sweating,  the  disease  resembling  an  attack  of  ague,  the  tendency 
to  perspiration  being  marked,  especially  while  the  patient  is  sleep- 
ing. Sometimes  there  is  but  the  one  chill,  the  succeeding  fever 
being  remittent,  and  rising  in  the  afternoon.  In  other  cases,  there 
may  be  no  febrile  action,  this  occurring  most  commonly  in  chronic 
cases.  The  temperature  rises,  in  febrile  cases,  as  high  as  103°  or 
104°  F.  during  the  afternoon,  declining  toward  morning.  Pain,  full- 
ness, weight,  and  tenderness  in  the  right  hypochondrium  attend 
these  symptoms,  the  area  of  liver-dullness  in  the  right  thorax  being 
enlarged,  and  the  liver  extending  downward  into  the  abdomen  a 
hand's  breadth  below  the  margin  of  the  ribs.  Fluctuation  may  occa- 
sionally be  detected  upon  palpation.  Respiration  is  impeded  by 
the  encroachment  upon  the  thoracic  space,  and  full  inspirations  are 
attended  by  increase  of  pain  in  the  right  hypochondrium.  The  pain 


DISEASES  OF  THE  LIVER.  489 

varies  in  character,  to  correspond  with  the  location  of  the  abscess, 
it  being  dull  and  aching  when  deeply  seated,  and  sharp  and  lancinat- 
ing when  so  near  the  surface  as  to  affect  the  peritoneal  covering. 
Pain  at  the  point  of  the  shoulder  or  angle  of  the  scapula  is  a  frequent 
symptom.  Sometimes  diffuse  peritonitis  may  arise,  and  the  lancin- 
ating pain  become  severe  and  wide-spread. 

Gastric  irritation  may  attend,  the  tongue  being  heavily  loaded; 
and  the  countenance  is  dull  and  expressionless  and  presents  a 
muddy,  icteric  hue.  Typhoid  symptoms  appear  early;  and  delirium, 
typhomania,  coma,  or  convulsions  may  soon  develop. 

When  the  purulent  accumulation  points  toward  the  thorax,  char- 
acteristic symptoms  arise.  If  the  lung  be  perforated,  a  violent  and 
harassino-  cough  arises,  and  soon  the  purulent  discharge  is  expecto- 
rated, the  reddish,  characteristic  material  resembling  anchovy  sauce, 
denoting  the  condition  in  tropical  abscess.  When  the  thorax  is 
invaded  within  the  pleural  cavity,  symptoms  of  pyothorax  arise. 

In  multiple  abscess  of  the  liver  the  symptoms  may  not  be  so 
active,  pyaemic  symptoms  attending,  the  liver  presenting  enlarge- 
ment, and  the  skin  assuming  an  icteroid  hue.  The  pain  and  tender- 
ness may  not  be  so  acute  as  in  single  abscess,  though  there  is  appre- 
ciable enlargement.  The  disease  runs  a  more  chronic  course,  but  is 
more  likely  to  prove  fatal  from  septicsemic  complication. 

Diagnosis. — The  chills,  febrile  symptoms,  and  enlargement  of 
the  liver,  with  pain  and  tenderness,  will  usually  call  attention  to  the 
liver  as  the  seat  of  inflammatory  disease.  Aspiration  will  decide  as 
to  whether  there  is  an  accumulation  of  pus.  It  is  to  be  recollected 
that  hepatic  abscesses  involve  the  upper  portion  of  the  organ  in 
most  instances,  and  here  is  the  place  to  aspirate  for  pus,  several 
trials  being  sometimes  necessary  in  multiple  abscess  in  order  to 
intersect  one,  and  locate  it  with  the  point  of  the  needle. 

Prognosis. — The  prognosis  of  pysemic  abscess  of  the  liver  is 
invariably  unfavorable.  Single  abscess,  under  modern  surgical 
methods,  may  often  be  brought  to  a  favorable  termination.  If  the 
disease  be  diagnosed  early,  and  potassium  chloride  3x  be  adminis- 
tered early  and  perseveringly,  arrest  of  suppurative  action  may  be 
accomplished  in  many  cases  of  traumatic,  if  not  in  tropical  abscess. 

Treatment. — The  early  administration  of  potassium  chloride  3x, 
five  grains  in  half  a  glass  of  water,  dose,  a  teaspoonful  every  hour, 
is  the  proper  medication  for  the  early  stages.  If  expectoration  of 
pus  suggest  the  discharge  of  the  abscess  through  the  lung,  a  con- 
servative course  may  be  better  than  a  radical  one,  the  complications 
being  met  as  they  arise  and  aspiration  of  the  lung  postponed.  The 
general  treatment  of  septicaemia  will  be  applicable  after  there  has 
been  purulent  accumulation. 


490  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

Section  of  the  abdominal  muscles,  down  to  the  liver,  with  subse- 
quent stitching  of  the  liver-tissue  to  the  abdominal  wall,  so  that  a 
surface  is  left  for  opening,  and  free  drainage  of  the  abscess,  is  prob- 
ably the  most  successful  method  of  treating  this  disease.  The  open 
abscess  then  becomes  an  ulcer  which  is  easily  treated  until  com- 
plete recovery  results. 

The  diet  should  be  free  from  fats  and  liquors,  and  consist  of 
small  quantities  of  fluid,  predigested  food,  such  as  pancreatinized 
milk  and  malted  milk,  and  animal  broths  free  from  fat.  If  there 
does  not  seem  to  be  enough  nourishment  in  such  diet,  eggs,  beaten 
in  milk,  may  be  used  sparingly,  food  being  taken  in  small  quantities 
at  a  time,  every  three  hours. 

NEW  GROWTHS  IN  THE  LIVER. 

THE  principal  new  growths  which  occur  in  the  liver  are  carcino- 
mata,  sarcomata,  angiomata,  and  adenomata.  To  these  may  be 
added  cystic  accumulations,  which,  though  not  strictly  new  growths, 
are  usually  considered  in  this  relation. 

Carcinoma  of  the  liver  may  occur  as  a  primary  affection,  and 
secondarily  from  infection  by  continuity  of  other  organs,  through 
the  lymphatics,  and,  at  an  advanced  stage  of  the  disorder,  through 
the  portal  vein  or  hepatic  artery.  Women  are  more  liable  to  it  than 
men,  and  it  is  rare  before  the  middle  of  life,  tendency  to  it  increas- 
ing after  that  time  to  the  sixty-fifth  year. 

Pathology. — Cancerous  growth  occurring  near  the  entrance  of 
the  portal  vein  may  so  obstruct  the  circulation  as  to  result  in  asci- 
tes  and  dilatation  of  the  radicles  of  its  collateral  branches.  In 
some  cases  the  cancer-growth  may  be  localized  in  a  small  portion  of 
the  liver  as  a  primary  growth,  and  numerous  nodules,  of  later  devel- 
opment, arise  secondarily.  In  other  instances,  the  entire  organ  may 
be  involved  in  primary  cancerous  growth  (massive  cancer).  Infil- 
tration of  the  liver  with  cancerous  elements  is  common  in  secondary 
infection  from  the  lymphatics  or  portal  vein,  the  development  of 
fibrous  growths  about  the  cancer  deposits  causing  a  general  resem- 
blance to  cirrhosis.  The  shape  of  the  liver  may  be  variously 
altered;  one  large  growth  may  be' surrounded  by  numerous  smaller 
distributed  nodules,  or  the  entire  surface  may  be  covered  with 
with  small,  irregular  nodules,  sometimes  projecting  from  the  sur- 
face, at  others  imperceptibly  grading  into  the  general  surface,  and,  in 
other  instances,  presenting  crater-like  depressions.  Hemorrhages 
may  occur  into  the  nodules,  and  suppuration  occasioually,  though 
rarely,  ensues.  Pressure  upon  the  biliary  passages,  from  contraction 
or  nodular  crowding,  is  not  an  uncommon  condition,  retention  of  bile 


DISEASES  OF  THE  LIVER  491 

and  hepatogenous  jaundice  resulting.  In  secondary  cancer  of  the 
liver,  the  organ  is  often  enormously  enlarged,  its  weight  sometimes 
exceeding  twenty  pounds.  The  nodules  project  beneath  the  capsule, 
and  may  be  plainly  felt  through  the  attenuated  abdominal  walls. 
Various  degenerative  changes  may  occur  in  the  morbid  structures, 
such  as  hyaline  or  fatty  degeneration,  or  sclerosis.  When  the  dis- 
ease originates  in  the  bile-passages,  it  is  usually  associated  with 
irritation  from  gall-stones,  and  the  cancerous  growth  frequently 
arises  in  the  base  of  the  gall-bladder.  Biliary  obstruction  from 
extension  of  the  process  to  the  common  or  hepatic  duct  is  liable  to 
arise,  with  retention  of  bile.  In  some  cases  the  disease  arises  pri- 
marily in  the  ducts.  Localized  peritonitis  often  gives  rise  to  adhe- 
sions of  the  capsule  to  surrounding  peritoneal  surfaces. 

Symptoms. — The  symptoms  of  hepatic  cancer  may  be  obscure 
in  the  beginning,  pain,  fullness,  and  icterus  being  attendants  of  vari- 
ous other  hepatic  disturbances.  The  cancer  cachexia,  however, 
becomes  marked  before  long,  and  gastric  symptoms  attend,  as  well 
as  those  of  biliary  and  portal  obstruction.  A  knowledge  of  primary 
cancer  preexisting  in  some  other  part,  such  as  the  rectum,  uterus, 
pylorus,  or  mamma,  renders  the  diagnosis  of  secondary  cancer  of 
the  liver  easy,  but  primary  cancer  of  the  organ  requires  more  care. 
When  the  cancerous  growth  is  located  near  the  periphery  of  the 
liver,  the  nodulated  surface,  with  its  crater-like  depressions,  may  be 
palpated  through  the  attenuated  abdominal  walls,  and  this,  in  con- 
nection with  the  loss  of  strength  and  flesh,  cachectic  pallor  of  coun- 
tenance, aud  tendency  to  rejection  of  food  by  the  stomach,  with  pain 
in  the  right  hypochondrium  or  beneath  the  right  shoulder  or  in  the 
dorsal  region  opposite,  suggests  the  condition  strongly.  Ascites 
usually  arises  as  a  result  of  obstruction  to  the  portal  circulation, 
and  oadema  of  the  feet  appears  at  a  late  stage. 

Though  hepatic  cancer  may  run  its  course  without  pain,  jaundice, 
or  ascites,  these  are  usually  prominent  symptoms.  The  pain  is 
often  lancinating,  this  being  due  to  involvement  of  the  peritoneal 
surface.  The  temperature  is  normal  or  subnormal  and  the  pulse 
small  and  rapid. 

Enlargement  of  the  cervical  and  inguinal  lymphatics  is  often 
present  from  cancerous  infiltration,  and  there  are  hematemesis  and 
mehena,  and  hemorrhages  from  the  mouth  and  vagina.  Eccbymotic 
spots  may  appear  on  the  skin. 

Diagnosis. — The  enlarged,  irregular-shaped  liver  suggests  the 
condition,  and  umbilication  of  the  nodules  establishes  the  diagnosis 
without  question.  When  palpation  fails  to  distinguish  this,  the  can- 
cerous cachexia,  in  connection  with  the  local  disturbances,  such  as 
pain,  irregular  enlargement  of  the  liver,  and  persistent  gastric  dis- 


492  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

turbance,  can  hardly  be  mistaken.  Aspiration  will  exclude  abscess 
from  the  diagnosis. 

Prognosis. — The  prognosis  of  hepatic  cancer  is  invariably 
unfavorable.  The  pain  and  other  discomfort,  however,  may  be  mod- 
ified by  rational  treatment,  and  much  suffering  thus  prevented. 
Medullary  cancer  of  the  liver  is  a  rapidly  fatal  disease,  usually  ter- 
minating within  from  two  weeks  to  four  months.  The  average  dura- 
tion of  cancer  of  the  liver  is  one  year. 

Treatment. — If  treatment  is  begun  early,  and  properly  perse- 
vered in,  many  of  the  severe  symptoms  may  be  averted,  and  the 
progress  of  the  disease  stayed  considerably.  Eclnnacea  not  only 
relieves  the  pain  of  cancer,  but  it  seems  to  fortify  the  system  against 
the  rapid  inroads  of  the  disease,  retard  the  rapidity  of  cancerous 
growth,  improve  assimilation,  and  prevent  the  rapid  dissemination 
of  the  cancer-elements,  while  it  lessens  anaemia  and  cachexia  A 
steady  use  of  this  remedy  is  therefore  advisable,  ten  or  fifteen  drops 
of  the  saturated  tincture  of  the  recent  plant  being  administered 
every  four  hours.  Chelidonium  may  be  alternated  with  this,  five  or 
ten  drops  of  the  specific  medicine  being  administered  every  four 
hours.'  Besides  a  supposedly  antidotal  influence  against  cancer, 
this  remedy  encourages  normal  hepatic  processes,  and  assists  in  the 
elimination  of  bile  from  the  biliary  passages,  thus  guarding,  in  some 
degree,  against  hepatogenous  jaundice.  The  diet  should  be  nutri- 
tious and  digestible. 

Sarcoma  of  the  liver  is  a  rare  disease,  though  it  occurs  in  a  few 
cases  primarily,  and  somewhat  more  frequently  secondarily.  It 
may  occur  in  the  form  of  lympho-sarcoma,  myxo-sarcoma,  or  glio- 
sarcoma.  Melano-sarcoma  is  a  variety  in  which  the  morbid  tissues 
are  pigmented,  presenting  the  appearance  of  dark  granite  or  deep 
black,  mottled  with  streaks  of  white  like  dark  marble ;  and  this  is 
the  form  usually  prevailing.  It  occurs  as  a  secondary  affection  fol- 
lowing sarcoma  of  the  eye  or  skin.  The  liver  becomes  much 
enlarged,  and  is  either  uniformly  infiltrated  with  the  morbid  growth 
or  nodular  masses  may  be  distributed  through  its  structure,  the  sur- 
face, however,  presenting  a  uniformly  smooth  appearance.  As  the 
blood  distributes  sarcoma  readily,  numerous  metastases  are  liaHr 
to  attend  the  liver-affection  early,  many  other  organs  being  involved. 
The  disease  is  most  liable  to  affect  the  young  and  those  before  mid- 
dle life. 

Adenomata  of  the  liver  occur  occasionally,  appearing  in  the  form 
of  small  encapsulated  tumors,  having  the  structure  of  the  liver. 
Their  presence  is,  however,  rare. 

Angiomata  of  the  liver  is  most  liable  to  occur  in  children,  and 
consist  of  masses  of  dilated  blood-vessels  about  the  size  of  a  walnut, 


DISEASES  OF  THE  LIVER.  493 

of  dark  reddish  color.  They  sometimes  attaiii  a  much  larger  size, 
increasing  the  bulk  of  the  liver,  though  the  liver-tissue  is  not 
altered.  They  usually  occur  singly. 

Cysts  of  the  liver  may  be  single  or  multiple,  and  usually  occur 
in  connection  with  congenital  cystic  kidneys.  Hydatid  cysts  (from 
echinococci )  will  be  considered  in  another  place. 

The  diagnosis  of  sarcoma  is  often  difficult,  the  pain  and  enlarge- 
ment being  common  to  other  morbid  conditions  of  the  liver,  though 
accompanying  sarcoma  of  the  stin  or  eye  will  furnish  a  valuable 
suggestion.  Angiomata  and  adenomata  are  recognized  with  difficulty, 
though  an  adenomatous  condition  generally  would  lend  color  to  a 
suspicion  of  adenomatous  growths  in  the  liver  if  hepatic  disturbance 
attended.  Persistent  hepatogenous  jaundice,  due  to  pressure  upon 
the  biliary  ducts,  gastric  disturbance,  and  enlargement  of  the  liver, 
are  among  the  constant  symptoms  of  all  new  growths  of  the  liver. 

The  treatment  cannot  be  specified.  Such  urgent  symptoms  as 
may  arise  should  be  met  by  the  judicious  administration  of  what, 
according  to  our  knowledge  of  materia  medica,  seemed  to  be  most 
urgently  demanded,  care  being  taken  to  avoid  opiates,  so  far  as  pos- 
sible. If  angionia  be  diagnosed,  calcium  fluoride  3x  may  be  admin- 
istered with  some  hope  of  benefit. 

FATTY  LIVER. 

Etiology  and  Pathology. — Fatty  liver,  in  some  form,  is  of 
frequent  occurrence.  It  may  occur  as  an  infiltration  or  a  degenera- 
tion under  abnormal  conditions,  and  physiological  infiltration  of  the 
cells  is  constantly  present  during  health,  and  increased  after  the 
ingestion  of  fatty  food.  The  liver-cells  which  lie  near  the  branches 
of  the  portal  vein,  i.  e.,  the  circumferential  cells  of  the  lobules, 
receive  the  fatty  deposit  first,  and,  in  abnormal  infiltration,  here  is 
where  the  process  is  most  observable.  For  the  disposal  of  fat  in  the 
portal  blood,  active  oxidation  must  occur  before  it  can  be  received 
by  the  hepatic  cells,  and  to  lack  of  proper  balance  between  fat-sup- 
ply and  oxidation  is  referable  abnormal  infiltration  of  the  liver  with 
this  material.  (1)  An  excess  of  non-nitrogenous  material  in  the 
blood  may  defeat  the  efforts  of  normal  oxidation,  and  an  undue 
amount  of  fat  thus  be  left  to  be  taken  into  the  hepatic  cells,  this 
condition  accompanying  excessive  deposit  of  fat  in  other  parts  of  the 
body  and  constituting  general  obesity,  a  condition  not  necessarily 
attended  by  impairment  of  function  or  danger  to  hepatic  integrity. 
(2)  A  normal  or  even  small  amount  of  fatty  material  in  the  portal 
circulation  may  result  in  fatty  infiltration  when  there  is  lack  of  a 
proper  supply  of  oxygen  for  its  consumption ;  and  fatty  infiltration 


494  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

of  the  liver  is  not  rare  in  phthisis,  anaemia,  and  other  cachexiae,  the 
deposition  of  fat  then  occurring  in  the  liver  while  other  parts  of 
the  body  are  undergoing  emaciation. 

Fatty  degeneration  or  fatty  metamorphosis  implies  a  destruction 
of  the  individuality  of  the  hepatic  cells  and  the  occupation  of  their 
sites  with  fat-globules  and  debris  of  the  preexisting  cells.  This  is 
a  much  more  serious  condition ;  for,  when  general,  it  implies  cessa- 
tion of  hepatic  function.  It  is  due  to  iupairment  of  the  vitality  of 
the  hepatic  cells,  through  the  local  influence  of  irritating  or  poison- 
ous substances,  such  as  toxines  and  phosphorus,  and  from  lack  of 
nutrition,  as  when  the  normal  blood-supply  to  a  lobule  or  group  of 
lobules  is  impoverished  or  cut  off,  as  in  anaemia,  cirrhosis,  etc. 

The  fatty  liver  is  uniformly  increased  in  size,  and  its  surface  is 
smooth  and  presents  a  bloodless,  pale  appearance.  On  section,  it 
is  dry,  and  it  cuts  as  though  greasy,  and  leaves  a  fatty  coating  on 
the  knife.  Sections,  and  even  the  entire  organ,  though  greatly 
enlarged  and  increased  in  weight,  may  float  in  water. 

Symptoms. — The  symptoms  are  not  very  striking  or  definite. 
Enlargement  in  the  right  hypochondrium  is  present,  the  edge  of  the 
enlarged  organ  sometimes  being  distinguishable  by  palpation  below 
the  navel,  soft  and  doughy  on  pressure.  It  is  not,  however,  painful  or 
sensitive.  Gastro-iutestinal  symptoms,  referable  to  pressure  and 
portal  obstruction,  are  frequently  prominent;  for,  though  there  may 
not  be  sufficient  pressure  upon  the  portal  canals  to  originate  ascites 
or  splenic  enlargement,  there  is  enough  to  congest  the  gastro-intes- 
tinal  mucous  membrane  and  interfere  with  the  digestive  functions. 
There  may  be  vomiting,  with  gastric  catarrh,  attacks  of  diarrhoea, 
and  other  symptoms  of  gastro-intestinal  dyspepsia,  with  loss  of 
strength,  anaemia,  drowsiness,  and  despondency.  Dyspnoea  arises, 
both  from  debility,  and  pressure  upon  the  diaphragm.  The  skin 
has  a  peculiar  smooth,  "velvety"  feel,  and  the  tissues  are  flabby  and 
inelastic.  The  biliary  functions  are  not  interfered  with  unless 
there  is  extensive  destruction  from  metamorphosis  of  the  hepatic 
cells,  and  jaundice  is  seldom  noticeable.  .  When  metamorphosis  of 
the  hepatic  cells  is  extensive,  rapid  anaemia,  exhaustion,  delirium, 
and  collapse  are  liable  to  occur  at  any  time,  the  stools  presenting  a 
pale,  clay-colored  appearance,  attacks  of  diarrhoea  then  frequently 
occurring. 

Diagnosis. — The  large,  rounded  liver,  with  smooth  surface  and 
inelastic  tissues,  will  not  be  confounded  with  cirrhosis  or  cancer,  in 
which  nodular  or  granulated  projections  are  distinguishable.  The 
only  disease  liable  to  be  confounded  with  it  is  waxy  liver,  and  here 
the  skin  is  dry  and  pale,  while  in  fatty  liver,  it  is  soft,  velvety, 
moist  and  shining.  In  fatty  liver  the  blood  is  hydrsemic,  while  in 


DISEASES  OF  THE  LIVER.  495 

waxy  liver  it  is  leukaemic.  The  history  of  waxy  liver  may  also 
assist  in  determining  the  matter,  as  syphilis  is  liable  to  result  in 
waxy  liver,  while  fatty  liver  seldom  follows  it.  The  waxy  liver  is 
hard  and  firm,  while  the  fatty  liver  is  soft  and  doughy.  In  fatty 
liver  the  urine  is  normal,  while  in  waxy  liver  it  is  albuminous,  and 
often  contains  casts.  The  spleen  is  enlarged  in  waxy  liver,  but 
remains  normal  in  fatty  liver. 

Prognosis. — The  character  of  the  fatty  accumulation  will 
determine  its  gravity.  Fatty  infiltration  is  not  a  serious  condition, 
but  fatty  metamorphosis,  when  extensive,  is  of  serious  nature. 

Treatment. — An  abstemious  diet  and  active  occupation  are 
conducive  to  recovery  in  all  curable  cases.  Plenty  of  out-door  exer- 
cise in  elevated  regions,  under  sanitary  conditions,  is  an  imperative 
part  of  treatment.  Oxygen  gas,  either  by  inhalation  or  by  rectum, 
improves  the  power  of  the  portal  blood  to  dispose  of  fatty  material, 
and  is  always  to  be  commended.  Phthisis,  syphilis,  and  other  con- 
ditions predisposing  will  demand  special  treatment.  Sugar,  starch, 
fats,  malt  liquors  and  alcoholic  drinks  should  be  considered  as  per- 
nicious, as  a  rule,  though  fatty  liver  may  exist  in  anaemic  or  pros- 
trated conditions  where  a  judicious  use  of  some  of  these  substances 
may  be  required.  Herberts  aquifolium  may  be  employed  to  improve 
the  digestive  power,  and  gastric  catarrh  may  require  hydrozone  or 
lavage  to  prevent  fermentative  action. 

AMYLOID  LIVER. 

Synonym. — Waxy  Liver. 

Etiology. — The  principal  cause  of  waxy  liver  is  syphilis.  It 
occurs  most  frequently  in  males  between  twenty-five  and  fifty  years 
of  age.  Prolonged  suppuration,  and  chronic  diseases  of  bone,  are 
other  prominent  causes,  phthisis,  ulceration  of  the  bowels  from 
chronic  dysentery,  chronic  pyelitis,  and  rickets,  being  most  fre- 
quently predisposing  causes  after  syphilis.  Prolonged  convalescence 
from  infectious  diseases,  especially  malaria,  and  any  form  of  cachexia 
attended  by  wasting  and  impoverishment  of  the  blood  may  finally 
develop  amyloid  degeneration  of  the  liver. 

Pathology. — The  amyloid  change  begins  in  the  radicles  mid- 
way between  the  center  and  periphery  of  the  lobules,  and  extends  to 
the  minute  branches  of  the  hepatic  artery.  A  material  of  nitroge- 
nous, homogenous,  translucent  appearance,  with  dull,  glistening  sur- 
face infiltrates  the  walls  of  the  capillaries  in  the  median  zone  of  the 
lobules,  and  extends  to  the  iuterlobular  vessels  and  connective-tis- 
sue, the  cells  being  but  little  involved.  "When  the  affected  tissues 
are  stained  with  iodine,  the  morbid  deposit  assumes  a  rich  mahog- 


196  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

any-brown.  The  entire  liver  is  enlarged,  firm  and  resistant,  the 
edges  sharply  defined  and  the  surface  smooth. 

Symptoms. — Enlargement  of  the  liver,  causing  bulging  in  the 
right  hypochoudrium,  with  increased  area  of  liver-dullness,  without 
pain  or  tenderness,  is  the  principal  symptom.  There  is  no  biliary 
obstruction,  and  jaundice  is  absent,  though  the  stools  may  be  light- 
colored.  The  spleen  is  occasionally  involved,  its  bulk  being 
augmented. 

Diagnosis. — This  is  usually  easy,  as  the  history  of  the  case 
will  account  for  the  gradual  and  progressive  enlargement  of  the  liver 
without  pain  or  tenderness.  Long-standing  suppuration,  syphilitic 
antecedents  or  persistent  cachexia,  followed  by  such  symptoms,  will 
naturally  support  a  theory  of  amyloid  degeneration. 

Prognosis. — Unfavorable.  Syphilitic  cases  may  be  modified 
and  life  prolonged  by  proper  treatment,  but  the  inevitable  result 
will  finally  be  death.  The  disease  runs  a  slow  course,  and  may 
drag  along  for  months,  and  sometimes  years,  such  complications  as 
diarrhoea,  purulent  peritonitis,  perihepatitis,  fatty  or  waxy  kidney, 
pulmonary  oedema,  pulmonary  gangrene,  etc.,  appearing  meanwhile. 
Death  may  finally  result  from  exhaustion,  anasarca,  diarrhoea,  urae- 
mia, or  other  causes  arising  from  varying  complications. 

Treatment. — Syphilis  should  be  properly  treated,  and  causes 
of  prolonged  suppuration  removed  if  possible.  Primary  diseases 
should  be  rectified  when  practicable,  and  anaemia  and  cachexia  cor- 
rected by  all  available  measures.  Each  case  will  suggest  its  medi- 
cinal treatment,  it  being  recollected  that  no  specific  remedy  can  be 
recommended  for  amyloid  degeneration.  All  that  can  be  done  is  to 
strive  to  correct  the  dyscrasia  upon  which  the  morbid  change 
depends. 

The  diet  should  be  considered,  and  sugars  and  starch  avoided, 
and,  when  the  stomach  is  fairly  active,  lean  beef  should  be  the  prin- 
cipal diet.  When  digestion  is  greatly  impaired,  predigested  foods 
may  be  required,  beef  peptonoids  and  pancreatinized  milk  being 
representative  forms  of  diet  When  the  disease  has  advanced  suffi- 
ciently far  to  be  readily  diagnosed,  little  time  will  usually  be  left 
for  treatment,  a  fatal  termination  soon  attending. 

TUBERCULOSIS  OF  THE  LIVER. 

TUBERCLES  may  be  deposited  in  the  liver  during  the  course  of 
general  tuberculosis,  and  in  connection  with  tubercular  disease  of 
the  intestines  and  mesenteric  glands,  though  there  are  few  distinct- 
ive features  attending,  ami  they  attract  little  more  than  pathological 
interest.  In  miliary  tuberculosis,  they  are  distributed  throughout 


DISEASES  OF  THE  BILE  PASSAGES.  497 

the  liver-tissue  in  small  masses,  while  in  the  chronic  forms  they  may 
occur  as  a  few  large  tubercular  deposits.  In  chronic  tuberculosis 
of  the  liver  there  is  usually  considerable  increase  in  the  amount  of 
connective  tissue,  and  the  deposits  are  liable  to  be  associated  with 
chronic  perihepatitis  or  peritonitis.  On  account  of  the  extensive 
proliferation  of  fibrous-tissue  atttending,  chronic  tuberculosis  of  the 
liver  is  usually  designated  as  "tubercular  cirrhosis." 


VIII.  DISEASES  OF  THE  BILE  PASSAGES. 

CATARRHAL  INFLAMMATION  OF  THE  BILIARY  PASSAGES. 

Synonym, — Catarrhal  Jaundice. 

Etiology  and  Pathology. — Eeference  to  this  disease  has 
been  made  under  jaundice,  but  completeness  demands  notice  of  it 
here.  It  arises  from  congestion  of  the  mucous  membrane  of  the 
common  bile  duct  in  most  cases,  though  it  has  been  asserted  that 
the  inflammation  may  begin  in  the  smaller  passages  and  extend  to 
the  larger  canal.  Duodenal  catarrh,  accompanied  by  indigestion, 
usually  originates  it,  the  inflammatory  action  extending  inward, 
from  the  intestinal  mucous  membrane.  Obstruction  of  the  biliary 
passage  may  be  due  to  accumulated  and  inspissated  mucus  in  the 
passages,  or  in  the  common  duct  alone,  the  common  point  of 
obstruction  being  in  the  pars  intestinalis,  that  portion  which  extends 
into  the  intestine.  It  occurs  frequently  in  young  persons,  though 
all  ages  are  liable  to  it,  indiscretions  in  diet,  colds,  malarial  attacks, 
and  all  causes  which  predispose  to  portal  obstruction,  being  liable 
to  be  followed  by  it.  It  sometimes  occurs  in  fevers,  pneumonia,  etc. 
Emotional  disturbances  are  sometimes  followed  by  jaundice  sup- 
posed to  be  due  to  this  condition,  and  it  may  occur  epidemically,  from 
unknown  causes. 

Symptoms. — Where  the  disease  is  due  to  continuity  of  intesti- 
nal irritation,  it  is  apt  to  be  preceded  or  attended  by  indigestion, 
flatulence,  and  constipation.  The  skin  rapidly  assumes  an  icteric 
hue,  the  color  being  bright  yellow,  and  never  the  greenish  tint 
observed  in  some  cases  of  grave  or  long-continued  jaundice.  Slight 
fever  may  attend,  though  the  temperature  is  rarely  above  101°  or 
102°  F.,  and  it  may  not  be  elevated  at  all.  In  the  epidemic  form, 
however,  there  is  liable  to  be  an  initiatory  chill,  followed  by  fever 
and  headache.  The  bowels  are  constipated  and  the  stools  are  clay- 
colored,  while  the  urine  contains  bile  pigment.  Though  the  pulse 
maybe  quickened  in  the  epidemic  variety,  and  may  sometimes  be 
normal  in  other  cases,  it  is  usually  abnormally  slow,  falling  as  low 
as  forty,  thirty,  or  even  twenty  beats  per  minute.  Slight  enlarge- 


498  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

ment  of  the  liver  may  occur,  though  its  size  may  be  normal  or  con- 
siderably enlarged.  The  duration  of  the  disease  varies  from  two  to 
twelve  weeks,  the  first  indication  of  returning  health  being  a  return 
of  the  normal  color  of  the  stools.  General  malaise,  muscular  pains, 
nausea  and  anorexia,  dizziness,  drowsiness,  and  indisposition  to 
exercise,  are  frequently  present. 

Diagnosis. — The  symptoms  are  of  such  a  mild  nature  and  occur 
so  suddenly,  while  the  patient  is  about,  or  follows  suddenly  upon 
an  acute  attack  of  gastro-intestinal  irritation,  that  there  is  little  dan- 
ger of  a  mistaken  diagnosis.  Other  forms  of  jaundice  come  on 
gradually,  or  are  much  more  severe  in  their  symptoms.  In  jaundice 
from  organic  disease  of  the  liver,  there  is  emaciation,  ascites,  and 
other  indications  of  portal  obstruction!  Weil's  disease  and  malig- 
nant jaundice  present  characteristic  symptoms. 

Prognosis. — The  prognosis  is  favorable,  rational  treatment 
usually  bringing  the  disease  to  a  speedy  close.  Even  badly  treated 
cases  may  recover  after  a  time,  without  serious  complication  or 
sequelae. 

Treatment. — The  treatment  of  this  form  of  inflammation  will 
depend  upon  the  conditions  presented.  If  febrile  symptoms  appear, 
aconite  and  rhus  tox.,  or  other  appropriate  sedative  treatment  may  be 
employed  in  the  beginning.  Malarial  manifestations  must  be  appro- 
priately met,  periodicity  being  interrupted  with  quinine  and  this 
may  be  followed  by  ten-drop  doses  of  grindelia  squarrosa  (green 
plant  tincture),  repeated  every  four  hours  during  the  day  and  eve- 
ning. The  most  appropriate  remedies  for  the  biliary  obstruction 
are  chelidonium  and  chionanthus,  either  in  combination  or  singly. 
Enemata  are  useful  to  assist  the  action  of  the  chologagues,  and  the 
use  of  the  salt  water  galvanic  electrode  in  the  lower  bowel,  with  the 
positive  pole  applied  over  the  hypochondriac  region,  is  an  excellent 
aid,  and  even  curative  measure,  in  a  large  majority  of  cases  in  which 
it  is  tried. 

GALL-STONES. 

Synonyms. — Cholelithiasis;  Biliary  Calculi. 

Definition. — Concretions  which  form  in  the  gall-bladder,  due 
to  inspissation  or  concentration  of  the  bile,  from  long  retention. 

Etiology. — It  is  believed  that  defect  in  the  sodium  salts  favors 
the  precipitation  of  cholesterin,  of  which  the  concretions  largely 
consist.  Inactivity  of  a  person  tends  to  the  production  of  biliary 
calculi,  those  of  sedentary  habits  being  most  prone  to  them,  the 
majority  of  cases  (75  per  cent)  occurring  in  women.  Pressure  upon 
the  cystic  duct  doubtless  favors  their  formation  by  obstructing  the 
free  flow  of  bile,  lacing  and  pregnancy  thus  rendering  women  excep- 


DISEASES  OF  THE  BILE  PASSAGES. 

tionally  prone  to  the  disease,  about  90  per  cent  of  the  cases  occur- 
ring in  women  affecting  those  who  have  borne  children.  It  has  been 
asserted  that  twenty-five  per  cent  of  all  women  past  sixty-five  years 
of  age  are  subject  to  gall-stones.  The  majority  occur  after  middle- 
life,  the  disease  being  rare  in  persons  less  than  thirty-five  years  of 
age.  A  fatty  diet,  an  excess  of  animal  food,  and  alcoholic  drinks  are 
supposed  to  figure  as  causal  factors. 

Pathology. — The  number  of  gall-stones  in  the  cyst  and  biliary 
passages  may  vary  from  one  to  a  thousand.  "Where  there  are  great 
numbers,  they  may  be  very  small — not  larger  than  a  small  bird-shot. 
Where  there  is  but  one  it  may  be  very  large,  sometimes  the  size  of 
a  lemon,  and  one  five  inches  in  length  has  been  reported.  The  very 
small  concretions  may  form"  in  the  small  bile-ducts,  but  the  large 
ones  originate  in  the  gall-bladder.  When  there  are  numbers  of 
these  concretions  in  the  gall-bladder  they  are  marked  with  facets, 
due  to  pressure  or  friction  from  one  another  being  polygonal  in 
form.  When  there  is  but  one,  or  a  few  which  are  not  crowded,  they 
may  be  oval  or  globular  in  shape.  If  a  smooth  section  of  a  gall- 
stone be  made  through  its  center,  it  will  be  seen  to  consist  of  con- 
centric layers,  surrounding  a  nucleus,  which  may  consist  of  bile-pig- 
ment, a  cast  of  an  hepatic  duct,  crystals  of  cholestrein,  cholate  of  lime, 
a  blood-clot,  a  fluke-worm  or  other  parasite,  etc.  The  separating 
lines  between  the  layers  or  concentric  rings  may  be  crossed  by  crys- 
talline radiations  of  cholesterin;  however,  this  substance  constitutes 
about  eighty  per  cent  of  all  gall-stones.  In  some  cases  there  may 
be  no  radiation,  the  concentric  layers  being  distinctly  separate. 
The  external  crust  varies  in  character  and  consistency,  though  the 
internal  structure  is  composed  largely  of  cholesterin.  Sometimes  it 
may  be  composed  principally  of  carbonate  of  lime,  and  will  then  be 
rough  and  of  whitish  color,  while  in  other  cases  it  may  consist  of  a 
mixture  of  cholesterin  and  pigment,  the  color  being  of  a  greenish- 
yellow  or  brownish  color,  and  smooth.  It  is  seldom  that  they 
undergo  erosion  or  disintegration,  their  structure  remaining  perma- 
nent, unless  they  increase  in  size  by  the  addition  of  material  to  their 
surfaces.  The  gall-bladder  resists  the  local  influence  of  the  concre- 
tions for  a  long  time,  and  may  not  be  very  much  altered  by  their 
presence,  though  the  mucous  membrane  may  finally  become  catarrhal 
and  eroded,  and  finally  the  entire  wall  may  become  thickened 
and  fibrous,  the  cyst  beiug  contracted  and  hardened  with  fibrous 
deposits,  or  converted  by  calcareous  degeneration  into  an  unyield- 
ing, stony  mass.  When  the  gall-bladder  is  impacted  with  calculi 
its  walls  may  be  ulcerated,  and  perforation  may  occur  with  escape 
of  the  calculi  through  the  abdominal  wall. 

Various  peculiar  changes  follow  the  impaction  of  a  calculus  in 


500  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

the  cystic  duct.  Ulceration  and  perforation  of  the  duct  with  escape 
of  the  calculus  into  the  abdominal  cavity  may  attend.  Dropsy  of 
the  gall-bladder  is  among  the  possibilities  of  the  case,  the  cyst 
becoming  enormously  distended  with  a  thin  mucoid  fluid,  several 
pints  being  sometimes  pent  up  in  its  cavity,  giving  rise  to  a  circum- 
scribed tumor,  which  may  be  mistaken  for  an  ovarian  cyst.  When 
the  calculus  passes  through  the  cystic  duct,  its  motion  is  rotary, 
from  the  peculiar  spiral  arrangement  of  the  mucous  folds  of  this 
passage.  When  impaction  of  the  cystic  duct  occurs,  symptoms  of 
jaundice  may  be  entirely  absent,  while  impaction  of  the  common 
bile-duct  would  be  attended  by  pronounced  hepatogenous  jaundice, 
the  bile  being  retained  and  absorbed  into  the  circulation.  Ulcera- 
tion and  perforation  of  this  duct  may  result  from  a  retained  and 
impacted  gall-stone,  as  well  as  in  the  case  of  the  cystic  duct.  From 
such  a  source  may  arise  fistulse  opening  through  the  abdominal  walls, 
into  the  duodenum,  colon,  stomach,  ureter,  pleural  cavity,  venacava, 
vagina,  and  other  organs,  leading  from  the  point  of  exit  of  the  calcu- 
lus through  the  wall  of  the  gall-bladder,  cystic  duct,  ductus  com- 
munis  choledochus,  etc. 

Symptoms. — The  most  common  symptom  of  gall-stone  is  bili- 
ary colic,  the  occasional  passage  of  a  calculus  being  attended  by 
excruciating  pain,  of  paroxysmal  character,  during  its  course  along 
the  bile-ducts  to  the  intestine.  The  first  experience  of  this  kind 
usually  marks  the  establishment  of  the  "gall-stone  habit,"  the 
patient  being  subject  to  more  or  less  frequent  attacks  of  hepatic 
colic  for  months  or  years,  unless  proper  treatment  be  instituted  to 
arrest  the  tendency  to  their  formation.  Biliary  colic  usually  arises 
after  some  peculiar  provoking  cause  which  produces  engagement  of 
a  calculus  in  the  biliary  passage,  the  predisposing  cause  probably 
being  pressure  from  behind,  due  to  accumulation  of  fluid  in  the 
cyst.  A  full  meal,  a  ride  over  a  rough  road  attended  by  jolting, 
active  exercise,  etc.,  being  immediately  followed  by  sudden  and 
severe  pain  in  the  right  hypochondrium,  which  is  aggravated  by 
change  of  position  and  pressure,  and  which  radiates  to  the  epigas- 
trium, along  the  diaphragm,  and  to  the  scapulae,  the  entire  upper 
portion  of  the  abdomen  being  sometimes  involved.  The  pain  is  bor- 
ing or  tearing  in  character,  and  comes  on  in  paroxysms,  these  often 
being  preceded  by  yawning,  rigors,  nausea,  vomiting,  and  profuse 
sweating.  The  face  becomes  pallid  and  clammy,  and  the  patient 
becomes  faint  and  prostrated ;  the  abdominal  muscles  are  rigid,  the 
pulse  is  small  and  oppressed,  and  the  patient  rolls  about  or  screams 
with  agony.  In  a  few  seconds  the  extreme  pain  may  subside  for  a 
short  interval,  to  return  again,  this  continuing  for  several  hours  or  a 
day,  when,  as  the  calculus  reaches  the  intestine,  the  pain  suddenly 


DISEASES  OF  THE  BILE  PASSAGES.  501 

ceases,  and  the  patient  becomes  comfortable,  though  prostrated,  and 
rapidly  returns  to  an  ordinary  condition  of  health,  with  prospects, 
however,  of  another  attack,  within  a  few  weeks,  at  least.  Symptoms 
of  hepatogenous  jaundice  may  attend  and  follow  the  attack,  the 
stools  being  clay-colored,  and  the  skin  and  conjunctive  icteric  in  hue. 
When  the  calculi  are  small  and  arise  in  the  biliary  ducts,  the  symp- 
toms of  jaundice  are  more  prominent  than  when  the  single  calculus 
originates  in  the  gall-bladder,  and  enlargement  of  the  liver  is  more 
prominent,  distention  of  the  gall-bladder  relieving  the  accumulation 
when  the  common  bile-duct  and  cystic  duct  are  involved.  Soreness 
in  the  right  hypochondrium  attends  and  follows  the  attack  for  a  few 
hours. 

Hy  drops  vesicce  fettece,  or  dropsy  of  the  gall-bladder,  arises  from 
chronic  obstruction  of  the  cystic  duct  by  gall-stones.  The  bile  is 
now  replaced  by  a  clear,  thin,  mucoid  fluid,  which  may  accumulate 
in  large  quantity,  the  entire  abdominal  cavity  being  sometimes  filled, 
the  enlargement  resembling  an  ovarian  cyst,  and  sometimes  being 
mistaken  for  it,  adhesion  to  the  broad  ligament  having  been  reported. 
Little  if  any  pain  attends,  and  jaundice  is  not  likely  to  be  present. 

Empymcea  of  the  gall-bladder  occasionally  occurs,  a  collection  of 
pus  accumulating  in  its  cavity,  and  this  is  usually  associated  with 
gall-stones.  An  enormous  amount  of  pus  may  thus  accumulate,  the 
quantity  sometimes  amounting  to  more  than  a  pint.  Final  perfora- 
tion of  the  cystic  walls  is  liable  to  occur,  with  the  formation  of  mul- 
tiple abscesses  in  the  neighborhood. 

Calcification  of  the  gall-bladder  sometimes  occurs,  this  usually 
being  a  sequel  of  empysema.  The  cystic  walls  become  stony  and 
unyielding,  the  mucous  membrane  and  sometimes  the  entire  struc- 
ture becoming  infiltrated  with  lime  salts. 

Phlegmonous  suppuration  of  the  walls  of  the  gall-bladder  occurs, 
though  it  is  rare.  The  symptoms  are  of  grave  character,  death  soon 
following  hyperpyrexia,  intense  abdominal  pain,  rapid  prostration 
and  peritonitis. 

Atrophy  of  the  gall-bladder  is  an  occasional  sequel  of  irritation 
from  gall-stones.  The  walls  become  contracted  until  the  cyst  is 
shrunken  to  a  mere  fibrous  cord,  or  a  nipple-like  protuberance  not 
larger  than  a  pea.  Sometimes  the  cyst  is  firmly  drawn  upon  a 
gall-stone. 

Divert  icida  are  sometimes  formed  in  the  gall-bladder,  in  which 
are  found  biliary  concretions. 

In  chronic  obstruction  of  the  common  duct  enlargement  of  the 
gall-bladder  is  not  common,  a  thin,  clear  mucus  being  found  in  the 
passages.  The  symptoms  of  this  condition  are,  paroxysms  of  chills, 
fever,°and  sweating,  not  unlike  those  of  ague,  attended  by  jaundice, 


DISEASES  OF  THE  DIGESTIVE  ORGANS. 

which  deepens  in  color  after  each  paroxysm,  and  may  continue  for 
months  and  even  years,  the  paroxysms  being  attended  by  severe 
pain  in  the  hypochondriac  region,  with  gastric  irritation  and  vomit- 
ing. Suppurative  cholangitis  may  follow  several  years  of  this 
condition. 

Suppurative  cholangitis  is  attended  by  remittent  fever,  followed 
by  hepatic  abscess,  or  perforation  of  the  gall-bladder,  with  abscess 
between  the  liver  and  stomach,  with  tenderness  of  the  abdomen  and 
septicaemia. 

Treatment. — The  treatment  of  biliary  colic  should  be  directed 
to  the  relief  of  the  severe  pain  during  the  paroxysms,  and  to  the  pre- 
vention of  the  formation  of  more  concretions  in  the  gall-bladder.  If 
the  latter  proposition  can  be  carried  out,  the  need  of  treatment  for 
more  serious  conditions  will  probably  be  done  away  with. 

During  the  passage  of  a  calculus,  a  napkin,  moistened  with  chlo- 
roform may  be  laid  against  the  hypochondrium,  and,  after  the  part 
becomes  accustomed  to  it,  may  be  allowed  to  remain  there,  though 
it  may  be  necessary  to  remove  it  every  few  seconds,  at  first,  on 
account  of  the  severe  burning  sensation  it  may  cause.  The  parox- 
ysms are  very  much  alleviated  by  this  local  application.  Large 
doses  of  dioscorea  and  gelsemium  should  be  administered  every  hour. 
fy  Specific  dioscorea,  gtt.  xv,  specific  gelsemium,  gtt.  x.  M.  and 
administer  in  a  swallow  of  water  at  a  dose.  During  the  paroxysms, 
the  inhalation  of  chloroform  may  be  practiced,  or  morphia  sulph. 
may  be  injected  hypodermically,  though  this  drug  hardly  suffices  to 
allay  the  pain,  in  safe  doses.  Chdidonium  and  chionanthus  have  been 
recommended  as  remedies  for  relief,  though  large  doses  of  dioscorea 
and  gelsemium  will  be  preferable. 

After  the  gall-stone  habit  has  been  detected,  preparations  of  /////- 
turn  should  be  regularly  administered  through  a  period  of  several 
months,  to  arrest  their  formation.  Dr.  Waterhouse  recommends  the 
benzoate  of  lithium,  used  by  dissolving  ten  grains  of  the  drug  in  an 
ounce  of  water  and  administering  a  teaspoonful  of  the  mixture  every 
three  or  four  hours.  Others  recommend  from  three  to  five  grains  of 
the  carbonate  of  lithium,  stirred  in  a  glass  of  water,  and  taken  at  a 
dose,  three  or  four  times  a  day.  Olive  oil,  taken  in  tablespoonful  or 
wine-glassful  doses  three  or  four  times  daily,  is  an  old  and  reliable 
remedy  for  the  habit.  The  galvanic,  salt-water  electrode,  used  in  the 
lower  bowel  with  the  negative  pole,  the  positive  being  applied  over 
the  right  hypochondrium,  is  an  excellent  measure  to  promote  fluid7 
ity  of  the  bile  and  encourage  normal  biliary  function.  In  the  treat- 
ment of  chronic  obstruction  from  biliary  calcuji,  the  conditions  of 
each  case  must  decide  the  course  to  pursue.  In  serious  affections 
of  the  gall-bladder,  cholecystotomy  is  the  proper  measure. 


DISEASES  OF  THE  PANCREAS.  503 

MISCELLANEOUS  AFFECTIONS  OF  THE  BILIABY-  PASSAGES. 

Cancer  of  the  gall-bladder  may  occur  as  an  independent  affection, 
either  primarily  or  secondarily,  though  there  are  many  difficulties 
in  the  way  of  diagnosing  it  from  cancer  of  the  liver,  and  there  is  lit- 
tle clinical  need  of  this.  It  usually  arises  from  the  irritation  of 
impacted  biliary  calculi. 

Stenosis  of  the  biliary  ducts  may  exist,  either  congenitally  or 
acquired  from  the  irritation  pf  impacted  gall-stones,  though  the  con- 
dition is  very  rare  in  either  case.  When  the  occlusion  is  acquired, 
it  usually  exists  low  down  in  the  common  duct.  Foreign  bodies  may 
obstruct  the  biliary  passages,  intestinal  worms,  fluke-worms,  echino- 
cocci,  the  seeds  of  various  fruits  and  other  accidental  substances, 
being  most  common  factors. 

Obstruction  from  pressure  from  without  is  more  common  than 
obstruction  from  internal  causes.  Carcinomatous  growths  from  neigh- 
boring viscera  are  the  usual  causes  of  such  obstruction.  The  pylo- 
rus, head  of  the  pancreas,  neighboring  lymphatic  glands,  stomach 
and  other  abdominal  organs,  may  be  the  seat  of  malignant  growths, 
which  exercise  pressure  upon  the  common  bile-duct,  to  occlude  it. 
The  symptoms  are  those  of  deeply  marked  icterus,  with  or  without 
hepatic  intermittent  fever;  and  hepatic  colic,  more  or  less  severe, 
alternates  with  painless  periods  and  gastric  disturbances,  with  grad- 
ual progression  toward  a  fatal  termination,  unless  the  obstruction  is 
removable.  The  diagnosis  is  obscure,  and  is  usually  determined  by 
an  autopsy. 

XI.  DISEASES  OF  THE  PANCREAS. 

HEMOERHAGE. 

Etiology. — The  causes  of  non-inflammatory  hemorrhage  of  the 
pancreas  are  somewhat  obscure.  Traumatism  undoubtedly  figures 
as  a  causal  factor  at  times,  and  self-digestion  may  occasionally  be 
responsible  for  it.  Hemophilia  and  purpura  may  also  be  reckoned 
among  occasional  causes. 

Pathology. — Diffused  blood  may  invade  the  parenchyma  of  the 
organ,  and  the  cellular  tissue.  Sometimes  the  hemorrhage  is  con- 
fined to  a  portion  of  the  gland,  while  at  other  times  the  entire  struc- 
ture of  the  pancreas  may  be  invaded. 

Symptoms. — The  principal  symptom  is  that  of  marked  and 
rapid  prostration,  amounting  to  collapse.  Pain  in  the  epigastric 
region  may  be  present,  and  sometimes  vomiting,  with  subnormal 
temperature.  If  death  does  not  soon  follow,  inflammation  sets  in 


504  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

about  the  hemorrhagic  areas.  Death  is  likely  to  occur  within  from 
half  an  hour  to  a  few  hours.  Should  inflammation  arise  the  case 
may  be  somewhat  prolonged,  acute  hemorrhagic  pancreatitis  being 
then  developed. 

Treatment. — Little  can  be  expected  from  treatment.  Stimu- 
lants, such  as  hypodermic  injections  of  strychnia  (gr.  l-50th  every 
half  hour  until  two  or  three  doses  have  been  administered),  and 
brandy  per  mouth  may  be  tried,  to  bring  about  reaction  from  the  col- 
lapse. Should  reaction  follow  and  inflammation  arise,  the  treatment 
will  be  that  for  hemorrhagic  pancreatitis. 

ACUTE  PANCREATITIS. 

Synonym. — Acute  Hemorrhagic  Pancreatitis. 

Etiology. — This  may  arise  from  traumatism,  alcoholisinus,  gas- 
tro-duodeuitis,  or  as  a  result  of  non-inflammatory  hemorrhage  of  the 
pancreas.  It  sometimes  follows  typhoid  fever,  pyaemia,  septicaemia, 
acute  tuberculosis,  and  parotitis  (metastasis).  Mercury  may  some- 
times be  responsible  for  it,  especially  when  its  use  has  been  pro- 
longed. 

Pathology. — The  organ  is  hyperaemic,  firm  in  consistency,  en- 
larged, and  its  substance  is  infiltrated  with  scattered  areas  of  small 
hemorrhages.  Sometimes  the  hemorrhage  is  more  extensive,  and 
infiltrates  the  omentum  and  contiguous  parts.  If  suppuration  has 
occurred,  small  abscesses  are  found.  In  febrile  diseases,  paren- 
chymatous  changes  may  take  place  through  the  entire  organ.  Sur- 
rounding parts  may  be  involved,  abscesses  arising  in  the  surround- 
ing connective  tissue  and  lymphatic  glands,  and  sometimes  the  pan- 
creas may  be  surrounded  by  pus,  which  may  finally  burrow  into  the 
stomach,  duodenum,  peritoneal  cavity  or  through  the  abdominal 
wall.  Tension  of  the  nerves  of  the  coaliac  plexus  may  give  rise  to 
intense  pain.  Fat  necrosis  seems  a  peculiarly  common  pathologi- 
cal condition  in  pancreatic  disease  and  it  is  sometimes  found  here, 
the  areas  of  necrosis  varying  in  size  from  that  of  a  pin-head  to 
that  of  a  hen's  egg,  scattered  through  the  pancreas,  omentum  and 
other  abdominal  organs.  Gangrene  sometimes  occurs,  cases  having 
been  reported  where  the  pancreas  was  entirely  sequestrated,  and  dis- 
charged as  a  slough  from  the  bowels. 

Symptoms. — Pain  of  colicky  nature,  over  the  region  of  the  pan- 
creas, with  prostration,  restlessness  and  anxiety,  are  the  leading 
symptoms.  The  pain  is  intense,  deep-seated,  and  radiates  to  the 
back,  shoulders  and  diaphragm.  There  is  difficult  and  sighing  res- 
piration, with  prostration,  nausea  and  vomiting,  distentlon  of  the 
epigastrium,  clammy  skin  and  cold  sweat  on  the  forehead.  Con- 


DISEASES  OF  THE  PANCREAS.  606 

stipation  is  the  rule,  though  diarrhoea  may  occur  as  a  metastasis 
of  the  inflammatory  action  to  the  intestine. 

Diagnosis. — The  diagnosis  is  difficult.  Acute  perforative  peri- 
tonitis or  intestinal  obstruction  is  more  liable  to  be  suspected. 
The  sudden  onset  and  intense  pain — seated  deeply  in  the  pancreatic 
region,  due,  probably,  to  tension  of  the  nerves  of  the  cceliac  plexus — 
would  suggest  the  condition,  especially  if  rapid  prostration  with 
Tomitiug  and  constipation  supervened,  though  these  symptoms  might 
also  be  present  in  obstruction  of  the  intestinal  canal. 

Prognosis, — Fatal  results  usually  follow  in  from  one  to  four 
days,  though  recovery  occasionally  results. 

Treatment. — The  therapeutics  of  acute  disease  of  the  pancreas 
are  not  in  an  entirely  satisfactory  condition.  Iodine,  in  minute 
doses  (3x  or  6x),  has  been  used  with  some  satisfaction,  and  iris  ver- 
sicolor  specifically  improves  the  recuperative  power  of  the  part. 
Both  remedies  may  be  thought  of  and  tried  in  cases  which  offer  any 
hope  of  even  a  few  hours'  lease  of  life.  Best  in  the  recumbent 
posture,  and  a  mild  and  unstimulating  liquid  diet,  must  be  en- 
joined, with  such  supporting  measures  as  the  extreme  prostration 
demands.  Strychnia,  hypodermically,  will  be  the  ideal  stimulant, 
care  being  exercised  to  employ  it  within  efficient  bounds. 

When  hemorrhage  seems  to  be  profuse,  as  indicated  by  symptoms 
of  excessive  prostration,  erigeron,  rhiis  aromatica  or  lycopus  may  be 
thought  of.  When  gangrene  is  suspected  the  use  of  echinacea  might 
be  advisable. 

CHRONIC  PANCREATITIS. 

Etiology. — This  disease  is  frequently  an  accr  •  ipaniment  of  dia- 
betes; whether  as  a  coincidence,  result  or  cause  is  not  yet  clearly  es- 
tablished. Calculi  may  originate  chronic  inflammation  and  indura- 
tion, as  also  may  pressure  from  tumors.  Chronic  inflammation  may 
invade  the  organ  from  other  parts,  as  in  ulceration  of  the  duodenum, 
stomach  and  other  neighboring  viscera.  Syphilitic  infection  some- 
times gives  rise  to  chronic  inflammation  of  the  pancreas. 

Pathology. — There  is  increase  of  the  interstitial  connective 
tissue,  as  in  cirrhosis.  Increase  of  the  connective  tissue  is  attended 
by  atrophy  of  the  glandular  structure,  the  organ  becoming  con- 
tracted, and  firmer  in  consistency  than  normal.  Closure  of  the 
duct,  calculi  and  cystic  formations  in  the  substance  of  the  organ  may 
be  results  of  constriction.  Interstitial  hemorrhages  are  likely  to 
occur  and,  in  the  suppurative  form,  pus  may  infiltrate  the  organ,  or 
one  or  two  small  abscesses  may  be  found.  Adhesions  frequently 
bind  the  organ  to  adjacent  parts. 


506  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

Symptoms. — Arrest  of  normal  function  may  interfere  with  the 
digestion  of  fats,  and  indigestion  attended  by  fatty  stools  will  nat- 
urally suggest  the  condition.  The  presence  of  a  transverse  tumor 
in  the  epigastrium,  deeply  seated,  will  add  to  the  symptoms.  Mel- 
lituria,  neuralgia,  emaciation,  etc.,  followed  (as  pressure  interferes 
with  the  portal  circulation)  by  ascites,  will  complete  the  picture. 

Treatment. — When  fatty  stools  appear,  the  free  use  of  olive  oil, 
with  a  spare  diet  free  from  fats,  in  which  pickled  olives  may  be  al- 
lowed ad  lib.,  may  prove  not  only  temporarily  beneficial,  but  perma- 
nently curative.  Two  or  three  ounces  of  olive  oil  should  be  admin- 
istered at  a  dose,  three  or  four  times  daily,  until  the  fatty  stools  are 
replaced  by  healthy  evacuations.  Meantime,  minute  doses  of  iris 
versicolor  and  iodine  may  be  alternated,  each  being  taken  three  or 
four  times  in  twenty-four  hours. 

If  the  inflammatory  condition  be  recognized  early,  much  benefit 
may  follow  the  use  of  potassium  chloride  3x,  through  its  influence  in 
controlling  plastic  exudation. 

FATTY  DEGENERATION. 

FATTY  infiltration  and  fatty  degeneration  both  occur  in  the  pan- 
creas, under  varying  circumstances.  In  fatty  infiltration  the  connec- 
tive tissue  becomes  involved  by  the  deposition  of  fat,  and  the  press- 
ure causes  gradual  disappearance  of  the  gland-cells  of  the  organ, 
complete  disappearance  of  secreting  structure  resulting  , until  the 
whole  gland  becomes  a  mass  of  fat,  with  the  duct  constituting  a 
central  canal.  In  j<My  degeneration  the  gland-cells  are  primarily  in- 
volved, the  destruction  not  including  the  cupsule,  septa  and  blood- 
vessels, which  remain  to  constitute  a  soft,  wasted,  flaccid  body, 
resembling  the  pancreas  in  shape,  but  lacking  its  secreting  power. 
The  causes  of  these  conditions  are  similar,  being  alcoholism,  general 
obesity  and,  in  degeneration,  heart  disease  and  obstruction  to  the 
escape  of  the  pancreatic  secretion. 

The  symptoms  are  obscure,  the  principal  ones  being  those  which 
arise  from  gradual  loss  of  function. 

WAXY  DEGENERATION. 

.WAXY  degeneration  of  the  pancreas  is  a  very  rare  disease,  and 
one  of  the  rarest  of  diseases  of  the  pancreas.  It  arise*  from  the 
usual  causes  of  amyloid  degeneration,  such  as  chronic  ulceration  of 
bone,  prolonged  suppuration,  syphilis,  etc.  The  diagnosis  is  ob- 
scure, and  treatment  is  of  little  avail,  a  fatal  termination  within  a 
few  months  being  inevitable. 


DISEASES  OP  THE  PANCREAS.  507 

CANCER  OF  THE  PANCREAS. 

Etiology. — Little  is  known  except  that  the  disease  occurs  most 
frequently  in  men  after  the  fortieth  year  of  age.  It  occurs  both  as 
n  primary  and  secondary  disease,  though  it  is  not  frequent  in  either 
form. 

Pathology. — Scirrlms  is  the  common  variety,  and  there  is  a  ten- 
dency to  inyolvement  of  adjacent  organs.  The  head  is  most  fre- 
quently affected  first,  and  pressure  upon  the  bile-duct  may  then  oc- 
cur, resulting  in  jaundice.  The  large  blood-vessels  in  the  vicinity  may 
be  obstructed,  crowding  upon  the  portal  vein,  giving  rise  to  accumu- 
lation of  ascitic  fluid.  The  canal  of  Wirsung  may  be  obstructed  and 
cysts  form,  from  tension  of  retained  secretion.  Ulceration  into 
neighboring  structures  may  occur,  as  breaking  down  proceeds. 

Symptoms. — The  symptoms  are  varied  and  often  obscure,  the 
variation  depending  upon  the  complications  which  arise  from  affec- 
tion of  neighboring  organs.  Where  the  head  is  largely  involved,  in 
thiii  persons,  a  deep  tumor  may  be  recognized  in  the  pyloric  region. 
Dyspeptic  symptoms,  intense  neuralgic  pains  of  paroxysmal  charac- 
ter in  the  pyloric  belt,  and  possibly,  though  not  necessarily,  fatty 
stools,  are  among  the  prominent  symptoms.  Kapid  emaciation  and 
loss  of  strength,  with  speedy  development  of  cancer  cachexia,  soon 
proclaim  the  malignant  character  of  the  disease,  which  only  re- 
quires to  be  located.  The  presence  of  free  hydrochloric  acid  and 
absence  of  coffee-ground  material  in  the  vomit  will  remove  suspicion 
of  gastric  cancer,  and  the  presence  of  stearrhoea  will  confirm  suspi- 
cion of  disease  of  the  pancreas.  Jaundice  with  these  distinguishing 
features  may  render  diagnosis  between  cancer  o^  the  pancreas  and 
liver  difficult.  Marked  pulsation  of  the  aorta,  communicated  to  the 
epigastrium,  would  be  a  diagnostic  aid  in  this  case,  suggesting  an 
impulse  communicated  by  the  hardened  pancreas. 

Treatment. — Little  can  be  done  to  stay  the  course  of  the  dis- 
ease, and  death  usually  occurs  within  a  year.  The  intensity  of  the 
suffering  may  be  modified  by  the  regular  administration  of  ten-drop 
doses  of  specific  echinacea,  repeated  three  or  four  times  daily.  To 
each  dose  one  or  two  drops  of  specific  iris  may  sometimes  be  added 
with  benefit.  A  spare  and  bland  diet,  consisting  of  pancreatinized 
meat  and  milk  should  be  employed,  and  the  patient  should  re- 
main quiet  in  bed. 

CALCULI  AND  CYSTS. 

CONCRETIONS  in  the  pancreatic  ducts  occasionally  obstruct  their 
lumen  and  cause  great  dilatation  and  distention  behind  the  point 
of  obstruction,  with  atrophy  of  the  gland  structure.  Pancreatic  con- 


608  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

cretions  are  usually  formed  chiefly  of  carbonate  of  lime,  are  round 
or  oval,  with  rough  or  spinous  surfaces,  and  present  a  white  or 
opaque  white  color.  When  numerous  they  cause  serious  dilatation 
of  the  pancreatic  ducts,  cystic  formations  arising  in  consequence. 
They  seldom  give  rise  to  abscess.  Obscure  colicky  pains  may  attend 
their  presence,  though  the  diagnosis  is  difficult.  Fatty  stools  and 
glycosuria  may  be  present,  though  not  necessary  symptoms.  Proba- 
bly pancreatic  calculi  occasionally  pass  in  the  stools. 

Pancreatic  cysts  commonly  result  from  impaction  of  the  ducts 
with  calculi.  Biliary  calculi,  lodging  at  the  orifice  of  the  common 
duct,  may  obstruct  the  duct  of  Wirsung,  and  pancreatic  concretions 
within  this  duct  or  its  branches  may  constitute  causal  factors.  Other 
causes  of  obstruction  of  the  pancreatic  duct  leading  to  similar  results 
are  cicatricial  contraction  af  the  duct  of  Wirsung  and  misplace- 
ments, by  which  a  passage  is  doubled  upon  itself.  Cicatricial  con- 
traction and  misplacements  may  be  due  to  injuries. 

A  pancreatic  cyst  may  attain  an  immense  size  and  be  mistaken 
for  an  ovarian  tumor,  though  usually  it  remains  in  the  epigastric  re- 
gion and  is  perceptible  upon  palpation  as  a  smooth,  lobulated  tumor, 
either  occupying  the  median  portion  or  one  side.  Aspiration  of  the 
contents  of  the  tumor  will  aid  in  diagnosing  the  case,  as  the  fluid 
will  emulsify  fat  and  convert  starch  into  sugar.  Disturbance  of  di- 
gestion, with  fatty  stools  and  glycosuria,  may  be  present. 

SARCOMA,  syphilis  and  tuberculosis  occasionally  involve  the  pan- 
creas. 

XII.  DISEASES  OF  THE  PERITONEUM. 

ACUTE  GENERAL  PERITONITIS. 

Definition. — Acute  inflammation  of  the  peritonaeum. 

Etiology. — This  disease  may  be  (1)  idiopathic  (primary),  or 
(2)  symptomatic  (secondary).  Primary  peritonitis  is  of  rare  occur- 
rence, though  it  may  arise  from  sudden  chilling  of  the  surface. 
To  this  form  the  term  "rheumatic  peritonitis"  has  been  applied. 
For  some  inexplicable  reason  the  peritonaeum  is  not  nearly  so  liable 
to  primary  inflammation  as  the  pleura  and  pericardium.  The  usual 
cause  of  acute  peritonitis  is  disease  of  some  abdominal  or  pelvic  vis- 
cus  (secondary  peritonitis).  Traumatism,  perforation  of  the  stom- 
ach or  bowel,  typhlitis,  metritis,  ovaritis,  rupture  of  the  gall-blad- 
der or  of  the  cystic  or  common  bile  duct,  surgical  operations  attend- 
ed by  opening  in  the  peritoneal  cavity,  etc.,  are  causes  of  secondary 
peritonitis. 


DISEASES  OF  THE  PERITONAEUM.  509 

Pathology. — The  inflammation  commonly  begins  in  some  cir- 
cumscribed place  and  afterward  becomes  more  or  less  rapidly  dif- 
fused over  the  entire  membrane.  A  mottled  appearance  is  observ- 
able early,  but  the  bright  redness  soon  becomes  general,  the  glisten- 
ing surface  of  the  membrane  disappearing  and  a  grayish  layer  of 
fibrillated  fibrin  exuding,  which  later  becomes  infiltrated  with  pus- 
cells.  The  bowels  are  inflated  with  gases,  and,  in  the  event  of 
abdominal  incision,  they  are  restrained  with  difficulty  from  escaping 
from  the  opening.  The  subserous  tissues  become  swollen  and 
oedema-tous,  and  filled  with  migrating  leucocytes  and  such  microbic 
forms  as  the  proteus  vulgaris,  streptococcus  pyogenes,  bacillus  coli 
communis,  and  pneumococcus,  which  are  also  found  in  the  exuda- 
tion. Adhesion  of  tlie  approximated  surfaces  occurs,  the  intestines 
becoming  glued  together,  to  other  viscera  and  to  the  abdominal 
walls,  the  peristole  becoming  thus  impaired.  Loops,  in  which  the 
bowel  may  be  incarcerated,  may  form.  The  character  and  amount 
of  the  exudation  varies,  there  sometimes  being  a  preponderance  of 
fibrin  and  sometimes  a  preponderance  of  serum.  The  fibrinous  ex- 
udation may  be  so  excessive  and  the  serum  so  scanty  as  to  con- 
stitute the  condition  sometimes  termed  "dry  peritonitis,"  while  in 
other  cases  there  is  a  large  amount  of  serous  exudation,  the  peri- 
toneal cavity  being  distended  by  a  considerable  amount  of  thin, 
watery  fluid,  which  may  be  mixed  with  pus  or  blood-corpuscles. 
Thus,  the  exudation  may  be  largely  fibrinous,  serous,  fibrino-puru- 
lent,  sero-fibrinous  or  sero-purulent,  etc.  The  appearance  of  the 
fluid  mav  vary.  In  some  cases  it  may  be  clear  and  colorless;  in 
others  (sero-fibrinous)  it  may  be  yellowish;  in  others  (purulent)  thin 
and  greenish-yellow  or  thick,  opaque  and  creamy;  in  others  (putrid) 
grayish-green,  with  putrid  odor,  the  latter  condition  being  the  result 
of  cancerous  disease  or  the  presence  of  fecal  or  other  material  due 
to  intestinal  or  other  visceral  perforation  and  escape  of  septic  fluids 
from  the  digestive  cavity. 

Symptoms. — The  disease  may  develop  gradually,  several  days 
being  occupied  in  the  appearance  of  the  general  and  local  symptoms 
before  they  are  fully  declared;  or  it  may  arise  suddenly,  this  being 
the  usual  course.  In  the  latter  case  a  chill  is  apt  to  indicate  the 
onset.  Pain,  of  burning,  lancinating  character,  is  always  present, 
localized  at  first,  but  becoming  diffused  with  more  or  less  rapidity 
all  over  the  abdomen.  Excerbations,  sometimes  amounting  to  spasms, 
alternate  with  periods  of  less  severe  suffering,  though  there  are  con- 
tinual burning  and  shooting  pains,  which  are  aggravated  by  move- 
ments of  the  diaphragm,  coughing,  sneezing,  vomiting,  deep  inspira- 
tion, and  even  upon  motion  of  the  body.  The  abdomen  becomes  more 
or  less  swollen,  from  accumulated  fluids  and  intestinal  gases,  and 


510  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

exceedingly  tender  to  pressure,  flexion  of  the  lower  extremities  usu- 
ally being  resorted  to  to  allay  tension  of  the  abdominal  muscles. 

Vomiting  frequently  occurs,  and  dyspnoea  is  an  invariable  symp- 
tom, this  being  due  to  the  fullness  of  the  abdomen  and  aggravation 
of  pain  upon  forced  descent  of  the  diaphragm.  The  temperature, 
during  the  reaction  following  the  chill,  may  rise  to  104°  or  105°  F. 
for  a  short  time,  but  it  afterward  falls  to  a  slight  elevation  above 
normal  and  remains  there,  or  at  least  it  seldom  afterward  rises  above 
102°  or  103°.  Sometimes  there  is  no  appreciable  elevation  of  tem- 
perature during  the  course  of  a  case.  The  pulse  is  rapid,  small  and 
hard  (wiry),  often  running  as  high  as  130  or  140  per  minute,  and 
ranging  from  110  to  150.  The  tongue  is  coated  white  at  first,  but 
becomes  dry  and  fissured  later,  of  deep-red  color  when  clean  and 
dark-brown  when  coated.  The  bowels  are  liable  to  be  loose  at  first, 
though  constipation  soon  follows.  The  urine  is  scanty  and  high- 
colored  and  contains  a  marked  quantity  of  indican.  Micturition  is 
usually  frequent,  though  enuresis  may  be  present  instead. 

The  decubitus  and  general  appearance  of  the  sufferer,  when  acute 
general  peritonitis  is  established,  is  characteristic.  The  patient  lies 
upon  the  back  with  the  knees  drawn  up,  with  the  abdomen  greatly 
swollen.  The  skin  over  the  face  is  shriveled  and  leaden  in  hue,  the 
eyes  are  sunken,  the  nose  is  sharp,  and  there  is  a  worn  and  anxious 
expression  about  the  countenance.  The  ears  are  cold  and  drawn, 
and  their  lobes  are  turned  out.  Tympanites  is  marked,  the  intestines 
being  distended  with  gases  and  crowded  under  the  diaphragm,  dis- 
placing the  heart,  liver  and  lungs  upward,  so  that  the  apex  beat 
may  be  heard  in  the  fourth  intercostal  space  and  the  usual  area 
of  liver  dullness  is  tympanitic.  Accumulation  of  ascitic  fluid  may 
give  rise  to  dullness  and  fluctuation  in  the  flanks. 

Diagnosis. — The  previous  history  of  a  case  will  assist  materi- 
ally in  arriving  at  a  correct  diagnosis.  A  knowledge  of  former 
appendicitis,  pelvic  inflammation,  typhoid  fev«r,  or  gastric  ulcer, 
would  be  suggestive,  when  active  symptoms  afterward  arose.  Peri- 
tonitis may  be  mistaken  for  intestinal  obstruction,  colic,  abdomi- 
nal neuralgia,  enteritis,  rheumatism  of  the  abdominal  muscles  or 
organs,  renal  or  biliary  colic,  suppurative  cellulitis  of  the  abdom- 
inal muscles,  or  the  imaginary  peritonitis  of  hysterical  persons.  In 
intestinal  obstruction  there  is  subnormal  temperature,  vomiting  of 
fecal  material  and  localized  pain  continually,  while  in  peritonitis 
the  pain  soon  becomes  diffused.  In  abdominal  neuralgia  there  is  no 
tympany,  no  rise  in  temperature  and  no  tenderness  upon  pressure, 
except  at  the  root  of  the  spinal  nerve  effected,  while  the  sensation  as 
of  a  cord  drawn  tightly  about  the  abdomen  prevails.  If  tympanites 
attends  enteritis  it  comes  on  slowly,  while  in  peritonitis  it  develops 


DISEASES  OF  THE  PERITONEUM.  611 

rapidly;  vomiting  is  a  common  and  frequent  symptom  in  enteritis, 
while  in  peritonitis  it  is  rare  and  the  vomit  consists  of  spinach- 
green  material.  In  abdominal  rheumatism  there  is  no  disturbance  of 
the  temperature,  the  pain  is  most  severe  at  the  point  of  insertion  of 
the  muscles,  there  is  no  tympanites,  unless  the  intestinal  muscularis 
is  involved  and  then  it  is  not  extreme,  no  vomiting,  and  no  tendency 
to  collapse.  In  biliary  and  renal  colic  the  pain  is  located  near  the 
part  involved,  is  peculiarly  paroxysmal,  unattended  by  fever,  and  there 
is  absence  of  tympanites  and  tenderness.  In  biliary  colic  symptoms 
of  jaundice  appear  after  twenty-four  hours,  and  in  renal  colic  the 
pain  radiates  along  the  ureter  to  the  testicle,  which  is  retracted. 
In  suppuration  of  the  abdominal  walls  there  is  not  such  intense 
pain  nor  such  marked  constitutional  symptoms. 

Prognosis. — Acute  diffuse  peritonitis  is  usually  rapidly  fatal, 
death  occurring  in  four  or  five  days  in  many  cases,  and  almost  in- 
variably within  ten.  Intense  forms  result  in  death  within  thirty- 
six  hours.  Feeble  action  of  the  heart,  with  irregular  action,  shal- 
low respiration,  livid  pallor  of  the  countenance,  and  coldness  of  the 
extremities,  with  high  rectal  temperature,  indicate  impending  dis- 
solution. 

Treatment. — The  plastic  exudation  is  to  be  controlled,  if  pos- 
sible, and  for  this  purpose  potassium  chloride  3x  should  be  admin- 
istered in  small  and  frequently-repeated  doses.  Ten  grains  may  be 
added  to  half  a  glass  of  water,  a  teaspoonful  being  administered  from 
this  every  hour.  In  this  place  the  potassium  chloride  proves  a 
sedative,  lowering  the  temperature  and  controlling  excessive  action 
of  the  pulse.  A  pack  of  towels  wrung  out  of  tepid  water  should 
be  applied  over  the  abdomen  and  changed  every  hour  or  two.  This 
treatment  promises  the  best  results  of  any  known  to  the  writer. 

Some  old  school  authors  advocate  the  use  of  opium  in  full 
doses,  repeated  sufficiently  often  to  maintain  complete  control  of 
peristalsis,  and  depend  upon  the  use  of  this  remedy  alone,  in  con- 
nection with  packs.  Where  septic  accumulation  in  the  peritoneal 
cavity  is  evidently  present,  abdominal  section  and  cleansing,  with 
subsequent  drainage,  is  practiced  by  many,  though  results  are  not 
usually  very  flattering.  In  all  cases  of  acute  diffuse  peritonitis,  a 
guarded  prognosis  must  be  made. 

In  puerperal  and  pelvic  peritonitis  especial  attention  is  to  be 
paid  to  the  condition  of  the  uterus  and  its  appendages,  proper 
douching  of  the  uterine  cavity  and  vagina,  being  considered  in- 
dispensable. 

Care  must  be  exercised  about  the  diet.  If  there  be  vomiting  all 
attempts  to  administer  food  or  drink  by  the  mouth  must  be  avoid- 
ed, and  nutrient  enemata  employed.  Where  vomiting  is  not  present 


512  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

very  small  quantities  of  precligested  milk  may  be  swallowed  fre- 
quently, only  a  little  being  allowed  at  a  time,  for  fear  of  exciting 
peristalsis  and  the  accumulation  of  gases.  If  water  be  allowed 
but  little  should  be  taken  at  a  time. 

PERITONITIS  IN  INFANTS. 

INFANTS  are  occasionally  subject  to  peritonitis,  congenital  syphilis 
being  the  most  frequent  cause.  In  this  instance  the  disease  may  so 
develop  during  the  prenatal  state  as  to  result  in  constriction  of  the 
bowel  from  fibrinous  adhesions.  A  cause  of  peritonitis  in  the  new 
born  is  irritation  of  the  umbilical  cord,  that  condition  extending 
to  the  abdomen  and  giving  rise  to  septic  peritoneal  inflammation. 

Peritonitis  in  older  children  is  liable  to  result  from  injuries  re- 
ceived at  boisterous  play,  or  from  kicks,  blows  or  bruises  about 
the  abdomen.  It  has  several  times  been  known  to  occur  as  an  epi- 
demic among  children  in  schools,  and  has  been  attributed  to  the 
effects  of  sewer-gas  poisoning. 

The  symptoms  of  septic  peritonitis  in  the  new-born  are  those 
which  usually  arise  in  other  forms  of  peritonitis,  complicated  with 
symptoms  of  malignant  jaundice.  There  is  marked  distentionof  the 
abdomen,  shallow  breathing,  evident  pain  upon  pressure  and  motion 
and  marked  jaundice,  with,  perhaps,  convulsions  or  coma. 

Little  can  be  expected  from  treatment.  Echinacea  or  echafolta, 
in  minute  doses,  may  neutralize  some  of  the  septic  conditions, 
though  the  accompanying  phlebitis  will  usually  prove  intractable 
to  treatment. 

LOCALIZED  PERITONITIS. 

PELVIC  PERITONITIS. — This  usually  arises  from  inflammation  of  the 
uterus  and  Fallopian  tubes,  due  to  puerperal  septicffimia,  gonorrhoeal 
infection,  or  tuberculosis.  Sometimes,  when  a  former  inflammation 
has  existed  in  the  pelvis,  sitting  on  cold  surfaces  or  sudden  chilling 
may  give  rise  to  the  inflammatory  condition  leading  to  it.  In  other 
cases  the  incautious  use  of  instruments  during  curettage  of  the  uter- 
us or  other  intra-uterine  operations  may  result  in  pelvic  peritonitis. 
The  disease  is  most  liable  to  arise  in  the  tubes,  the  fimbriated  ex- 
tremity becoming  inflamed,  swollen  and  covered  with  exudate  which 
glues  the  affected  part  to  the  ovary  and  drags  surrounding  tissues 
together  into  an  unrecognizable  mass,  the  broad  ligament  becoming 
infiltrated  with  pus,  and  purulent  accumulation  distending  the  Fal- 
lopian tubes,  sometimes  to  the  extent  of  bursting.  Rupture  of  one 
of  the  Fallopian  tubes  or  of  an  abscess  of  the  broad  ligament  may 
cause  general  peritonitis.  Tuberculosis  of  the  pelvic  tissues  may 


DISEASES  OF  THE  PERITONEUM.  613 

give  rise  to  localized  peritonitis.  The  symptoms  are  localized  pain, 
with  swelling  and  tenderness  of  the  parts,  slight  elevation  of  temper- 
ature, especially  in  the  evening,  chilly  sensations,  and  hectic  fever. 
There  is  more  or  less  obstruction  of  the  bowels,  loss  of  appetite  and 
general  derangement  of  the  stomach.  Throbbing  sensations  in  the 
pelvis  soon  attend.  The  only  successful  plan  of  treatment  is  the 
early  and  steady  use  of  potassium  chloride  3x.  When  this  is  begun 
early  and  persevered  in,  the  affection  can  usually  be  controlled 
before  the  formation  of  pus,  and  the  inflammation  subsides  by  reso- 
lution. Add  ten  grains  of  potassium  chloride  3x  to  half  a  glass  of 
water  and  order  a  teaspoonful  every  hour.  Follow  this  day  after  day 
for  three  or  four  weeks.  A  liquid  diet  should  be  prescribed,  and 
an  occasional  mild  laxative  of  salts  or  decoction  of  rhamnus  cali- 
fornica  bark. 

APPENDICULAB  PERITONITIS. — This  is  the  most  frequent  form  of 
localized  peritonitis  in  the  male.  Appendicitis  has  already  been 
fully  considered,  and  the  reader  is  referred  to  that  article  for  the 
pathology,  symptoms  and  treatment. 

SUBPHBENIC  PERITONITIS. — The  lesser  peritonaeum  may  be  involved 
in  localized  inflammation  arising  from  perforations  of  certain  parts 
of  the  stomach,  colon  or  duodenum,  inflammation  of  the  pancreas, 
or  pyo-thorax.  The  lesser  peritonaeum  may  become  distended  with 
fluids,  forming  a  tumor  which  may  be  mistaken  for  cyst  of  the 
pancreas.  Accumulations  of  pus  may  occur  here  (perihepatic  ab- 
scess), and  even  distention  of  the  part  with  air,  the  latter  condition 
being  due  to  communication  with  the  lung,  stomach  or  bowel.  In 
some  cases  traumatic  perforations  are  followed  by  a  similar  con- 
dition. The  symptoms  are  characterized  by  severe  localized  pain 
confined  to  the  epigastrium,  which  may  be  abrupt  in  its  onset,  par- 
ticularly when  due  to  perforation  of  the  stomach  or  bowel,  and  this 
is  often  accompanied  by  vomiting  of  bilious  or  sanious  material. 
With  these  symptoms  develop  fever,  chills,  emaciation,  and  suppura- 
tion. Perforation  into  the  lung  is  announced  by  cough  and  profuse 
expectoration.  The  prognosis  in  such  cases  is  doubtful,  surgical 
interference  offering  the  only  hopeful  prospect. 

CHRONIC  PERITONITIS. 

Etiology. — Chronic  peritonitis  may  follow  an  attack  of  acute 
peritonitis,  or  may  arise  gradually  from  irritation  of  an  abdominal 
viscus.  It  is  believed  that  it  sometimes  arises  idiopathically,  though 
such  cases  are  probably  really  due  to  new  growths,  such  as  cancer 
or  tubercle.  The  following  varieties  of  chronic  peritonitis  may  be 

34 


614  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

mentioned:  (1)  Local  adhesive,  (2)  diffuse  adhesive,  (3)  prolifer- 
ative  and  (4)  hemorrhagic. 

Local  adhesive  peritonitis  arises  as  secondary  to  inflammatory  dis- 
ease of  one  of  the  abdominal  viscera.  Its  favorite  locality  is  about 
the  liver  and  spleen.  The  symptoms  are  not  marked,  though  per- 
sistent abdominal  pain  may  attend  some  cases,  others  occasioning  no 
inconvenience  and  being  overlooked,  unless  discovered  accidentally 
upon  autopsy.  Sometimes  loops  are  formed  by  adhesions,  into 
which  the  intestines  may  be  incarcerated,  giving  rise  to  intestinal 
obstruction. 

Diffuse  adhesive  peritonitis  results  from  acute  inflammation  of  the 
peritonaeum.  Here  the  peritonaeum  may  be  completely  obliterated, 
th»  visceral  and  abdominal  layers  being  welded  together  and  the 
intestines  matted,  the  adhesions  usually  involving  the  liver  and 
spleen. 

Proliferative  peritonitis  is  characterized  by  remarkable  thickening 
of  the  peritonaeum,  without  adhesion  of  its  surfaces.  It  occurs  in 
cancer  and  tuberculosis  of  the  peritonaeum,  and  in  cirrhotic  con- 
ditions of  the  liver  or  portions  of  the  intestinal  canal,  often  in 
subjects  of  chronic  alcoholism.  The  peritonaeum  is  white  and 
opaque  in  appearance,  generally  thickened,  though  there  are  patches 
where  the  thickening  is  greatly  exaggerated.  About  the  liver  and 
spleen  this  may  be  marked,  a  layer  of  gristly  connective  tissue  half 
an  inch  or  more  in  thickness  sometimes  enveloping  these  organs. 
Constriction  of  the  inclosed  viscera  attends,  and  they  become  much 
reduced  in  size.  Sometimes  the  constriction  results  in  obstruction 
to  the  portal  vein.  Thickening  of  the  intestinal  walls  may  occur,  and 
the  abdominal  viscera  may  be  drawn  up  into  a  ball  not  much 
larger  than  a  child's  head.  There  may  be  moderate  effusion  and 
sometimes  marked  ascites,  though  in  other  cases  the  peritonaeum 
may  be  divided  into  several  sacs,  each  containing  circumscribed 
fluid.  Friction-sounds  in  these  cases  are  usually  heard  in  the  upper 
portion  of  the  abdomen.  Nodular  thickening  has  been  observed  in 
rare  cases,  which  has  been  determined  to  be  neither  tubercular  nor 
cancerous,  and  which  has  been  supposed  to  be  due  to  the  presence 
of  parasites.  Nodules  of  this  character  may  be  disseminated  through 
the  liver.  A  Japanese  investigator  asserts  that  the  nodules  contain 
the  ova  of  a  parasite. 

Chronic  hemorrhagic  peritonitis  is  characterized  by  the  successive 
formation  of  new  connective  tissue  upon  the  surface  of  the  periton- 
aeum containing  open  blood-vessels,  from  which  exude  blood-stained 
effusions.  The  hemorrhagic  formations  are  usually  circumscribed, 
and  commonly  occur  in  cancer  and  tuberculosis. 

Treatment. — With  our  present  means  of  treatment  little  can  be 


DISEASES  OF  THE  PERITONEUM.  515 

done  for  chronic  peritonitis,  except  to  keep  the  patient  quiet  and 
enjoin  the  use  of  a  spare  animal  diet,  with  almost  complete  avoidance 
of  vegetables  and  starchy  food.  Potassium  chloride  3x  may  sometimes 
assist  in  controlling  plastic  exudation,  especially  when  used  patiently 
and  persistently  for  a  long  time.  An  important  step  is  the  preven- 
tion of  ascitic  accumulations  in  the  intestines,  and  careful  attention 
to  diet  will  accomplish  the  most  of  this,  vegetables,  sugars  and 
starches  being  objectionable.  Broiled  tender  chops,  steaks,  white 
meat  of  fish  or  chicken,  in  small  quantities  and  carefully  and  slowly 
masticated,  are  best  adapted.  When  the  stomach  digests  them  eggs, 
milk  and  cream  may  be  taken.  To  alleviate  the  formation  of  gases 
half  a  drachm  of  listerine  or  five  grains  of  eudoxine  may  be  adminis- 
tered half  an  hour  or  so  after  eating. 

NEW  GROWTHS  IN  THE  PERITONEUM. 

THE  peritonaeum  may  be  the  seat  of  tubercular  and  cancerous 
growths,  as  well  as  of  nodules  resulting  from  the  presence  of 
echinococci. 

Tubercular  peritonitis  may  be  primary  and  local.  It  may  attend 
tuberculosis  of  the  lungs  or  follow  an  attack  of  acute  miliary  tuber- 
culosis. It  is  common  in  children,  more  frequent  in  males  than  in 
females,  and  is  most  apt  to  be  found  between  the  ages  of  twenty  and 
forty,  though  it  may  occur  in  advanced  life.  Extensive  thickening 
aud  adhesions  occur,  the  omentum  being  puckered  and  bunched  and 
drawn  across  the  upper  portion  of  the  abdomen.  Sacs  are  formed, 
in  which  accumulations  of  sero-purulent  or  purulent  material  are 
found,  the  amount  varying,  though  the  entire  abdomen  may  be  dis- 
tended, as  in  ascites.  Localized  abdominal  tumors  may  represent 
omaller  collections.  General  wasting  of  flesh,  digestive  disorders, 
and  more  or  less  abdominal  pain  are  the  leading  symptoms.  The 
temperature  is  remarkably  prone  to  be  subnormal,  a  morning  range 
of  95.5°  F.  often  being  found.  Treatment  can  accomplish  little  here, 
palliative  measures  only  being  applicable.  Opiates,  dietary  regula- 
tions and,  in  some  cases,  surgical  relief  of  distended  accumulations 
are  the  principal  means  to  be  relied  upon. 

Cancerous  growths  in  the  peritonaeum  may  be  primary  or  second- 
ary, the  latter  condition  being  the  rule  and  simplifying  the  diagnosis. 
When  occurring  secondarily  the  stomach  or  ovary  is  usually  the 
starting  point.  Cancerous  nodules  are  distributed-  over  the  peri- 
toneal surface,  and  the  omentum  becomes  puckered  and  drawn  up  as 
in  tuberculous  peritonitis,  forming  a  transverse  tumor  across  the 
upper  portion  of  the  abdomen.  The  disease  is  disseminated  by  con- 
tact of  opposing  surfaces  (transplanted)  or  through  lymph  currents 


616  DISEASES  OF  THE  DIGESTIVE  ORGANS. 

which  carry  the  cancer  cells  to  different  parts.  The  diagnosis  is  not 
difficult  when  the  disease  is  secondary  to  localized  cancer,  but  when 
primary  there  is  so  much  resemblance  to  tuberculous  peritonitis  in 
many  respects  that  there  may  be  confusion.  Cancer,  however,  pre- 
sents more  marked  nodulation,  this  being  apparent  on  palpation 
when  ascitic  fluids  have  been  evacuated.  There  is  greater  pain  in 
cancer  usually,  and  the  cancerous  cachexia  is  more  or  less  apparent. 
Treatment  is  not  highly  satisfactory.  Echinacea  may  be  tried  for  the 
pain,  paracentesis  will  relieve  oppressive  distention  of  the  abdomen, 
and  rest  and  proper  diet  may  assist  in  prolonging  life. 

Echinococci  give  rise  to  nodular  growths  on  the  peritonaeum,  these 
occurring  in  connection  with  hydatids  of  the  liver.  There  is  not  much 
danger  of  confounding  this  affection  with  cancer  or  tubercle,  as  the 
general  health  is  not  much  involved,  the  principal  trouble  arising 
from  pressure  of  the  morbid  growth.  The  enlarged  liver  will  origi- 
nate the  leading  symptoms,  which  will  be  mechanical. 

A8CITE8. 

Synonyms. — Abdominal  Dropsy;  Hydroperitonaeum. 

Definition. — An  accumulation  of  serum  in  the  abdominal  cavity. 

Etiology. — Ascites  may  occur  during  the  late  period  of  general 
dropsy,  though  it  usually  arises  from  portal  obstruction,  the  vis  a 
tergo  from  the  abdominal  arteries  then  forcing  the  serum  from  the 
capillaries  into  the  peritoneal  cavity.  Allforms.of  peritoneal  inflam- 
mation are  attended  by  more  or  less  effusion  into  the  peritoneal  cav- 
ity due  to  capillary  changes,  and  sometimes  the  amount  may  be  suf- 
ficient to  distend  the  peritoneal  sac  to  its  utmost  limits.  Diseases 
of  the  heart  or  lungs  which  contribute  to  obstruction  in  the  venae 
cavaa  may  be  attended  by  ascites,  though  general  dropsy  is  more 
liable  to  attend  such  condition.  The  common  causes  of  ascites  are 
those  which  give  rise  to  portal  obstruction,  such  as  cirrhosis  of  the 
liver,  hepatic  cancer,  biliary  obstruction,  pressure  from  tumors  or 
cicatricial  bands  and  thrombus  of  the  portal  vein.  Asthenic  condi- 
tions may  be  attended  by  ascites  when  there  is  no  obstruction  to 
the  circulation,  as  in  hydraemic  states  of  the  blood  due  to  anaemia, 
chlorosiw,  malarial  cachexia,  purpura,  chronic  arsenical  poisoning, 
chronic  Bright's  disease,  and  senility  or  great  exhaustion,  the  condition 
then  being  considered  asthenic  or  cachectic  ascitet.  Sudden  arrest 
of  secretion  from  chilling  of  the  surface,  especially  during  menstrua- 
tion, or  the  sudden  suppression  of  cutaneous  affections,  may  be  fol- 
lowed by  it.  Tuberculous  or  cancerous  disease  of  the  peritonaeum 
is  apt,  after  degenerative  changes  have  become  well  established,  to 
be  attended  by  dropsy. 


DISEASES  OF  THE  PERITONEUM.  517 

Pathology. — The  endotbelia  of  the  peritonaeum  are  swollen, 
and  manifest  more  or  less  fatty  degeneration.  They  appear  turbid, 
and  the  subserous  tissue  is  increased  in  bulk,  the  entire  membrane 
appearing  soggy  and  inelastic.  The  fluid  in  the  abdominal  cavity 
varies  from  a  few  ounces  to  five  or  six  gallons.  It  may  be  viscid  or 
watery  in  consistence,  and  is  usually  of  a  yellowish  straw  color  with 
an  opalescent  greenish  tint,  though  if  there  be  an  admixture  of  blood 
it  may  be  dark,  while  in  disease  of  the  lymphatics  it  may  be  milky. 
Sometimes  it  is  as  clear  and  as  limpid  as  water.  Chylous  fluid  may 
depend  upon  perforation  of  the  thoracic  duct  from  cancerous  disease, 
or  upon  filariae.  The  specific  gravity  varies  from  high  to  low,  though 
it  is  usually  as  low  as  1.010  or  1.015.  The  blood  of  ascitic  patients 
is  usually  hydrsemic  and  poor  in  albumen. 

Symptoms. — Gradual  increase  in  the  size  of  the  abdomen  is  the 
characteristic  symptom  of  ascites.  With  this  will  be  associated  the 
symptoms  which  attend  the  particular  etiological  factor  of  each  indi- 
vidual case.  Portal  obstruction,  various  forms  of  peritonitis,  ca- 
chexise  and  other  provoking  conditions  manifest  themselves  in  con- 
junction. Where  there  is  biliary  obstruction  there  may  be  marked 
symptoms  of  jaundice.  In  other  cases  the  patient  may  present  a 
pallid  appearance,  or  the  waxy  color  of  cancer  may  be  prominent. 

Physical  signs  are  important  as  diagnostic  symptoms.  Palpation 
imparts  a  peculiar  wave  to  the  fingers,  which,  without  doubt,  attests 
the  presence  of  fluid  in  the  cavity.  The  fingers  of  one  hand  should 
be  placed  upon  one  side  of  the  abdomen  while  a  sharp  tap  is  given 
upon  the  opposite  side  with  the  other  hand.  A  distinct  wave  passes 
across  and  imparts  its  shock,  whenever  there  is  fluid  in  the  abdo- 
men, to  the  stationary  fingers.  Percussion  elicits  information  of  fur- 
ther value;  change  of  position  alters  the  relative  location  of  the 
fluids,  which  impart  dullness,  and  the  intestines,  which  give  reso- 
nance. In  the  upright  position  the  fluid  gravitates  to  the  lower  part 
of  the  abdomen,  and  the  intestines  rise  toward  the  diaphragm,  dull- 
ness being  found  upon  percussion  of  the  lower  part  of  the  abdomen 
and  resonance  when  percussion  is  made  higher  up  over  tha  intes- 
tines. When  the  patient  is  in  the  dorsal  position  the  dullness  will 
be  in  the  flanks  and  the  tympanitic  sounds  over  the  middle-line  of 
the  abdomen.  When  the  patient  is  turned  upon  the  side  the  dull- 
ness will  be  over  the  lower  flank  and  the  tympanitic  sound  over  the 
upper  one.  Change  of  position  will  thus  be  followed  by  change  of 
location  of  dullness  and  resonance,  corresponding  to  the  shifting 
of  the  fluid  and  intestines  due  to  gravity.  In  case  there  is  a  very 
small  amount  of  fluid  the  knee-chest  position  may  be  necessary  to 
detect  it. 

Ascites  should  be   differentiated  from  a  large  ovarian  tumor  cen- 


518  DISEASES  OF  THE  DIGESTIVE  ORGANS 

trslly  placed,  which  remains  fixed  centrally  and  pushes  the  intestines 
into  the  flanks.  Here  the  points  of  dullness  are  reversed  when 
the  patient  is  in  the  dorsal  position  from  those  of  ascites.  A  dis- 
tended bladder  may  be  mistaken  for  abdominal  dropsy,  and  the 
awkward  act  of  plunging  a  trocar  into  the  viscus  has  been  committed 
by  surgeons  in  the  past,  though  this  may  seem  an  incredible  error. 
The  condition  of  the  bladder  should  always  be  determined  before 
the  operation  of  paracentisis.  Pancreatic  and  hydatid  cysts  have  been 
confused  with  ascites,  though  such  errors  should  not  occur  with 
careful  attention  to  diagnostic  points. 

Treatment. — The  treatment  of  ascites  should  be  adapted  to  in- 
dividual cases.  The  causal  or  provoking  factor  should  receive  first 
attention.  Portal  obstruction,  if  amenable  to  treatment,  should  be 
removed,  and,  in  malarial  cachexia,  spleen  remedies  should  be  admin- 
istered to  assist  normal  portal  circulation.  Hydraemic  conditions 
may  require  calcium  phos.  3x,  calcarea  carb.  3x,  preparations  of  iron, 
change  of  climate  or  other  provision.  The  diet  should  be  generous, 
unless  digestion  is  seriously  impaired,  and  as  small  an  amount  of 
fluid  as  possible  should  be  taken.  Heroic  measures  for  the  removal 
of  abdominal  fluids  should  be  avoided.  Hot  or  steam  baths  are  not 
adapted  to  this  condition.  Active  cathartics  seldom  accomplish 
permanent  good,  and  prove  debilitating  from  the  start.  Sometimes, 
when  there  is  not  serious  organic  disease  present,  cathartic  doses  of 
elaterium,  employed  for  a  few  hours  at  intervals,  remove  the  fluid,  and 
judicious  after-management  prevents  its  return.  The  use  of  diuretics 
and  diaphoretics  is  favored  by  many,  but  such  measures  seldom 
accomplish  much.  Apocynum  cannabinum,  in  five-  or  ten-drop  doses 
of  the  specific  medicine,  four  or  five  times  daily,  may  prove  success- 
ful. In  other  cases  benefit  might  follow  the  use  of  convallaria  mo/oZtff, 
in  five-drop  doses  repeated  every  three  or  four  hours  during  the  day. 
Sometimes,  when  the  accumulation  is  due  to  arrested  cutaneous  ex- 
udation, a  change  of  climate  will  serve  the  purpose.  In  the  case  of 
an  old  sea  captain  with  enormous  ascitic  accumulation,  a  prolonged 
residence  in  the  interior  of  California  resulted  in  a  permanent  cure. 
Of  course,  in  this  case  there  was  no  organic  disease  or  portal 
obstruction. 

Most  cases  finally  become  so  distressing  from  distention  as  to 
need  paracentisis,  and  this  may  require  repetition  a  number  of  times, 
whatever  the  ultimate  result.  Important  considerations  in  such 
cases  are  precautions  as  to  asepsis  of  instruments  employed,  and 
care  not  to  injure  any  of  the  abdominal  viscera. 


INDEX. 


ABDOMINAL  DROPSY 516 

ABNORMALITIES  OF  THE  HEPATIC 

CIRCULATION 478 

ABSCESS  OF  THE  LIVER 486 

Synonym,  486. 

Etiology,  486. 

Pathology,  487. 

Symptoms,  488. 

Diagnosis,  489. 

Prognosis,  489. 

Treatment,  489. 

ABSCESS,   PERITONSILLAR 366 

ACTINOMYCOSIS 291 

Synonyms,  291. 

Definition,  291. 

Etiology,  291. 

Pathology,  291. 

Symptoms,  291. 

Diagnosis,  291. 

Prognosis,  292. 

Treatment,  293. 
ACUTE  ARTICULAR  RHEUMATISM  .  302 

Synonyms,  302. 

Definition,  302. 

Etiology,  302. 

Pathology,  302. 

Symptoms,  302. 

Diagnosis,  303. 

Prognosis,  304. 

Treatment,  304. 
ACUTE  CATARRHAL  ENTERITIS.  ..412 

ACUTE  DIARRHCEA 412 

ACUTE  DYSPEPSIA 376 

ACUTE  DYSPEPTIC  DIARRHCEA — 466 

ACUTE  ENTERO-COLITIS 412 

ACUTE  ENTERO-COLITIS  (INFAN- 
TILE)  467 

ACUTE  GASTRIC  CATARRH 376 

Synonyms,  376. 

Definition,  376. 

Etiology,  376. 

Pathology,  376. 

Symptoms,  376. 


ACUTE  GASTRIC  CATARRH,  CONT'ED. 

Diagnosis,  377. 

Prognosis,  377. 

Treatment,  378. 
ACUTE  GENERAL  PERITONITIS.  ...508 

Definition,  508. 

Etiology,  508. 

Pathology,  509. 

Symptoms,  509. 

Diagnosis,  510. 

Treatment,  511. 
ACUTE  GENERAL  TuBERCULOSis.,268 

Synonyms,  268. 

Definition,  268. 

Etiology,  268. 

Pathology,  270. 

Symptoms,  271. 

Diagnosis,  272. 

Prognosis,  272. 

Treatment,  272. 

ACUTE  HEMORRHAGIC  PANCREA- 
TITIS  504 

ACUTE  INFECTIOUS  JAUNDICE.... 295 
ACUTE  INTESTINAL  CATARRH 412 

Synonyms,  412. 

Definition,  412. 

Etiology,  412. 

Pathology,  413. 

Symptoms,  413. 

Treatment,  413. 

ACUTE  MILIARY  TUBERCULOSIS. ..268 
ACUTE  PANCREATITIS 504 

Synonym,  504. 

Etiology,  504. 

Pathology,  504. 

Symptoms,  504. 

Diagnosis,  505. 

Prognosis,  505. 

Treatment,  505. 
ACUTE  PHARYNGITIS 358 

Definition,  358. 

Etiology,  358. 

Symptoms,  359. 


520 


INDEX. 


ACUTE  PHARYNGITIS,  CONT'D 358 

Treatment,  359. 

ACUTE  RHEUMATISM 302 

ACUTE  YELLOW  ATROPHY  OF  THE 

LIVER 476 

ADENOMATA  OF  THE  LIVER 492 

AFRICAN  FEVER 165 

AGUE 222 

AMYLOID  DEGENERATION  OF  THE 

BOWELS 455 

AMYLOID  LIVER 495 

Synonyms,  495. 
Etiology,  495. 
Pathology,  495. 
Symptoms,  496. 
Diagnosis,  496. 
Prognosis,  496. 
Treatment,  496. 

ANGINA  LUDOVICI 364 

ANGINA  MALIGNA 167 

ANGINA  SUFFOCATA 167 

ANGIOMATA  OF  THE  LIVER 492 

ANTHRAX 258 

Synonyms,  258. 
Definition,  258. 
Etiology,  258. 
External,  258. 
Internal,  259. 
Treatment,  260. 

APPENDICITIS 444 

Definition,  444. 
Etiology,  444. 
Pathology,  445. 
Symptoms,  446. 
Diagnosis,  447. 
Prognosis,  447. 
Treatment,  448. 

APPENDICULAR  PERITONITIS 513 

APHTHA 349 

APHTHOUS  STOMATITIS... 349 

Synonyms,  349. 
Definition,  349. 
Etiology,  349. 
Pathology,  349. 
Symptoms,  349. 
Treatment,  349. 

ARREST  OF  SALIVARY  SECRETION..357 
Synonym,  357. 
Etiology,  357. 
Symptoms,  357. 
Treatment,  358. 
ARTHRITIS  DEFORMANS.  . .  .  .311 


ARTHRITIS  DEFORMANS,  CONT'D.. 311 
Synonyms,  311. 
Definition,  311. 
Etiology,  312. 
Pathology,  312. 
Symptoms,  313. 
Diagnosis,  314. 
Prognosis,  314. 
Treatment,  314. 

ASCITES. 516 

Synonyms,  516. 
Definition,  516. 
Pathology,  517. 
Symptoms,  517. 
Treatment,  518. 

ASIATIC  CHOLERA 200 

Synonyms,  200. 
Definition,  200. 
Historical  Note,  200. 
Etiology,  201. 
Pathology,  202. 
Symptoms,  203. 
Complications,  205. 
Diagnosis,  205. 
Prognosis,  205. 
Treatment,  206. 

ATROPHIC  CIRRHOSIS 482 

ATROPHY 36 

ATROPHY  OF  THE  GALL-BLADDER.. 501 

BACILLI,  PATHOGENIC 67 

BACTERIOLOGY 60 

Technology  of,  60. 
Staining,  Preparing,  62. 
Biology  of,  64. 

BARLOW'S  DISEASE 341 

BIG  JAW H'.u 

BILIARY  COLIC 500 

BILIOUS  REMITTENT  FEVER i^'.t 

BILIOUS  TYPHOID  OF  GREISIN- 

GER 295 

BLACK  VOMIT 208 

BLATTER 108 

BLITZ  CATARRH 161 

BLOODY  FLUX 425 

BOWELS,    AMYLOID   DEGENERA- 
TION OF 455 

BOWELS,  INFLAMMATION  OF 

412,  413,  419,  420,  42T, 

BLOODVESSELS  OF  LIVER,  DIS- 
EASES OF 478 

BRAUNE  PRUNA. .  ..167 


INDEX. 


621 


CAECUM,  INFLAMMATION  OF 443 

CALCULOUS  DEGENERATION 46 

CALCULI,   BILIARY 498 

CALCULI  OF  THE  PANCREAS 507 

CANCER  OF  THE  GALL  BLADDER..503 
CANCER  OF  THE  INTESTINES 433 

Etiology,  433. 

Pathology,  434. 

Symptoms,  434. 

Diagnosis,  436. 

Prognosis,  436. 

Treatment,  436. 
CANCER  OF  THE  LIVER 490 

Pathology,  490. 

Symptoms,  491. 

Diagnosis,  491. 

Prognosis,  492. 

Treatment,  492. 
CANCER  OF  THE  PANCREAS 507 

Etiology,  507. 

Pathology,  507. 

Symptoms,  507. 

Diagnosis,  507. 

Treatment,  507. 

CANCER  OF  THE  PERITONAEUM...  .515 
CANCER  OF  THE  STOMACH 398 

Etiology,  398. 

Pathology,  399. 

Symptoms,  400. 

Diagnosis,  402. 

Prognosis,  402. 

Treatment,  402. 

C ANCRUM  ORIS 353 

CARTILAGE,  INFLAMMATION  OF..  24 

CATARRH.  ACUTE  GASTRIC 376 

CATARRH,  ACUTE  INTESTINAL  . .  .412 

CATARRH,  BLITZ 161 

CATARRHAL   FEVER 161 

CATARRHAL  INFLAMMATION  OF 

THE  BILIARY  PASSAGES 4!»7 

Synonym,  497.  , 

Etiology  and  Pathology,  497. 

Symptoms,  498. 

Diagnosis,  498. 

Prognosis,  498. 

Treatment,  498. 
CATARRHAL  ENTERITIS,  ACUTE.. 412 

CELLULITIS  OF  THE   NECK 364 

CEREBRO-SPINAL  FEVER 101 

Synonyms,  101. 

Definition,  101. 

Historical  Note,  101. 


CEREBRO-SPINAL  FEVER,  CONT'D...IOI 

Etiology,  101. 

Pathology,  101. 

Symptoms,  102. 

Diagnosis,  105. 

Prognosis,  106. 

Treatment,  106. 

CEREBRO-SPINAL  MENINGITIS  ____  101 
CHICKEN  Pox  .....................  123 

Synonym,  123. 

Definition,  123. 

Etiology,  123. 

Pathology,  124. 

Symptoms,  125. 

Diagnosis,  126. 

Prognosis,  127. 

Treatment,  127. 
CHILLS  AND  FEVER  ...............  222 

CHOLERA,  ASIATIC  .................  206 

CHOLERA  INFANTUM  ..............  461 

CHOLERA  MORBUS  ................  403 

Synonyms,  431. 

Definition,  431. 

Etiology,  431. 

Pathology,  431. 

Symptoms,  431. 

Diagnosis,  432. 

Prognosis,  432. 

Treatment,  433. 
CHOLERA  NOSTRAS  ................  431 

CHRONIC  ARTICULAR  RHEUMA- 

TISM ...........................  307 

Synonym,  307. 

Definition,  307. 


Pathology,  307. 

Symptoms,  307. 

Diagnosis,  308. 

Prognosis,  308. 

Treatment,  308. 

CHRONIC  CATARRHAL  ENTERITIS  .  .415 
CHRONIC  ENTERO-COLITIS  .  .......  415 

CHRONIC  DIARRHCEA  .............  4  1.~> 

CHRONIC  DYSPEPSIA  ..............  .".TH 

CHRONIC  GASTRIC  CATARRH  ......  379 

CHRONIC  GASTRITIS  ...............  379 

Synonyms,  379. 

Definition,  379. 

Etiology,  379. 

Pathology,  380. 

Symptoms,  381. 

Diagnosis,  382. 


522 


INDEX. 


CHRONIC  GASTRITIS,  CONT'D 379 

Treatment,  383. 

Prognosis,  383. 

CHRONIC  GASTRIC  ULCER 392 

CHRONIC  INFLAMMATION 25 

CHRONIC  INTESTINAL  CATARRH.. 415 

Synonyms,  415. 

Etiology,  415. 

Pathology,  416. 

Symptoms,  416. 

Diagnosis,  416. 

Prognosis,  417. 

Treatment,  417. 
CHRONIC  MALARIAL  FEVER 251 

Synonyms,  251. 

Definition,  251. 

Etiology,  251. 

Pathology,  251. 

Symptoms,  251. 

Diagnosis,  252. 

Prognosis,  253. 

Treatment,  253. 
CHRONIC  PANCREATITIS 505 

Etiology,  505. 

Pathology,  505. 

Symptoms,  505. 

Treatment,  506. 
CHRONIC  PERITONITIS 513 

Etiology,  513. 

Treatment,  513. 

CHRONIC   HEMORRHAGIC    PERITO- 
NITIS  514 

CHRONIC  PHARYNGITIS 360 

CHRONIC  TONSILLITIS 368 

Synonyms,  368. 

Definition,  368. 

Etiology,  368. 

Pathology,  369. 

Symptoms,  369. 

Diagnosis,  369. 

Prognosis,  369. 

Treatment,  370. 

CIRRHOSIS 27 

CIRRHOSIS  OF  THE  LIVER 480 

CLERYMAN'S  SORE  THROAT 360 

Cocci,  PATHOGENIC 66 

COLIC,  BILIARY 500 

COLIC,  BILIOUS 461 

COLIC,  COPPER 462 

COLIC,  INTESTINAL 461 

COLIC,  LEAD 462 

COLLOID,    DEGENERATION 44 


CONGESTION  OF  THE  LIVER,  PASS- 
IVE  478 

CONGESTIVE  FEVER 235 

CONSTIPATION 458 

Definition,  458. 

Etiology,  458. 

Pathology,  459. 

Symptoms,  459. 

Diagnosis,  459. 

Prognosis,  459. 

Treatment,  459. 

CONTAGIOUS  C ATABRH 161 

CONTINUED  MALARIAL  FEVER... 243 

COPPER  COLIC 462 

CORNEA,  INFLAMMATION  OF 24 

CROUPOUS  ENTERITIS 418 

CROUPOUS  STOMATITIS 349 

CYSTS  OF  THE  LIVER 493 

CYSTS  OF  THE  PANCREAS 507 

DANDY  FEVER 165 

DEGENERATIONS 41 

"  AMYLOID 45 

"  CALCAREOUS 46 

"  COLLOID 44 

"  MUCOID 44 

"  PARENCHYMAT'S.  42 

"  PIGMENTARY 47 

DENGUE 165 

DENGUE  FEVER 165 

Synonyms,  165. 

Definition,  165. 

Etiology,  165. 

Pathology,  166. 

Symptoms,  166. 

Diagnosis,  166. 

Prognosis,  167. 

Treatment,  167. 
DIABETES  INSIPIDUS 331 

Synonyms,  331. 

Definition,  331. 

Etiology,  331. 

Pathology,  333. 

Symptoms,  332. 

Diagnosis,  332. 

Prognosis,  333. 

Treatment,  333. 
DIABETES  MELLITUS 326 

Synonyms,  326. 

Definition,  326. 

Etiology,  326. 

Pathology,  326. 


INDEX. 


623 


DIABETES  MELLITUS,  CONT'D 326 

Symptoms,  327. 

Diagnosis,  329. 

Prognosis,  329. 

Treatment,  329. 
DIARRHCEA 456 

Definition,  456. 

Etiology,  456. 

Symptoms,  457. 

Treatment,  457. 

DIARRHCEA,  CHRONIC 415 

DILATATION  OP  THE  STOMACH.  .  .390 

Synonym,  390. 

Definition,  390. 

Etiology,  390. 

Pathology,  390. 

Symptoms,  391. 

Diagnosis,  391 

Prognosis,  392. 

Treatment,  392. 

DlTHTHERIA 167 

Synonyms,  167. 

Definition,  167. 

Historical  Note,  168. 

Etiology,  168. 

Pathology,  171. 

Nature  of,  173. 

Symptoms,  174. 

Diagnosis,  178. 

Prognosis,  179. 

Treatment,  179. 

DlTHTHERITIC  ENTERITIS 418 

DISEASES  OF  THE  MESENTERY  ...  470 

DROPSY,  ABDOMINAL 516 

DRY  DIET 54 

DUKE  OF  WURTEMBERG'S  CURE. .  .  54 
DYSENTERY 425 

Synonyms,  425. 

Definition,  425. 

Etiology,  425. 

Pathology,  426. 

Symptoms,  427. 

Diagnosis,  427. 

Prognosis,  427. 

Treatment,  427. 
DYSPEPSIA,  CHRONIC   379 


ECHINOCOCCI     OF     THE    PERITO- 
NAEUM  516 

ECZEMA  OF  THE  TONGUE 352 

Synonyms,  352. 
Definition,  352. 


ECZEMA  OF  THE  TONGUE,  CON.  .  .352 

Etiology,  352. 

Symptoms,  352. 

Treatment,  352. 

ELEPHANTIASIS 286 

ENGLISH  CHOLERA 431 

ENTERIC  FEVER 69 

ENTERITIS,  ACUTE  CATARRHAL.  .412 
ENTERITIS,  CHRONIC  CATARRHAL  415 

ENTERITIS,  CROUPOUS 418 

ENTERITIS,  MEMBRANOUS 418 

ENTERO-COLITIS,  CHRONIC 415 

ENTERO-COLITIS  (INFANTILE)  . . .  .467 

ENTERORRHAGIA 441 

EPIDEMIC  CATARRH 161 

EPIDEMIC  CHOLERA 200 

EPIDEMIC  INFLUENZA 161 

Synonyms,  161. 

Definition,  161. 

Historical  Note,  161. 

Etiology,  162. 

Pathology,  162. 

Symptoms,  162. 

Treatment,  162. 

EPIDEMIC  ROSEOLA 150 

ERYSIPELAS 187 

Synonyms,  187. 

Definition,  187. 

Etiology,  187. 

Pathology,  188. 

Symptoms,  189. 

Diagnosis,  190. 

Prognosis,  191. 

Treatment,  191. 
ESTIVAL  INFANTILE  ENTERITIS.  .464 

Synonyms,  464. 

Etiology,  464. 

Pathology,  465. 

FAMINE  FEVER 97 

FARCY 289 

FATTY  CIRRHOSIS 483 

"       DEGENERATION 43 

"  "  OF  THE 

PANCREAS 506 

FATTY  INFILTRATION 42 

"       LIVER 493 

Etiology  and  Pathology,  493. 
Symptoms,  494. 
Diagnosis,  494. 
Prognosis,  495. 
Treatment,  495. 


524 


INDEX. 


FEBRICULA 293 

FEBRIS  FLAVA 208 

FEVER 1 

Synonyms,  1. 

Definition,  1. 

Detection,  1. 

Classification,  1. 

Thermometry,  2. 

Stages,  2. 

Termination,  3. 

Remissions,  3. 

Causes,  3. 

Parasitic  Origin,  4. 

Symptoms,  5. 

Tissue  Changes,  7. 

General  Treatment,  7. 

Ventilation,  8. 

Diet,  8. 

Special  Sedatives,  10. 

Antiseptic  Sedatives,  12. 

Antiperiodics,  14. 

Opiates,  16. 

Muscular  Pain,  17. 

Cathartics,  17. 

FEVER,  CATARRHAL 161 

CEREBRO-SPINAL 101 

CONGESTIVE 235 

DANDY 165 

DENGUE 165 

CHRONIC  MALARIAL 251 

CONTINUED  MALARIAL.  .  .243 

MALARIAL.. 316 

PERNICIOUS  MALARI AL  . . 235 
REMITTENT  MALARIAL  .  .229 

"        RELAPSING 97 

SCARLET 128 

TYPHOID 69 

TYPHO-MALARIAL. 243 

TYPHUS 90 

"        YELLOW 208 

FCETID   STOMATITIS 350 

Synonyms,  350. 

Definition,  350. 

Symptoms,  350. 

Treatment,  350. 

FOLLICULAR  STOMATITIS 349 

FOLLICULAR  TONSILLITIS. 364 

Synonym,  364. 

Definition,  364. 

Etiology,  364. 

Pathology,  364. 

Symptoms,  365. 


FOLLICULAR  TONSILLITIS,  CON... 364 

Diagnosis,  365. 

Prognosis,  365. 

Treatment,  365. 
FUNCTIONAL  GASTRIC  DYSPEPSIA. 406 

Synonym,  406. 

Definition,  406. 

Etiology,  406. 

Pathology,  406. 

Symptoms,  407. 

Diagnosis,  407. 

Prognosis,  407. 

Treatment,  407. 


GALL-STONES 

Synonyms,  498. 

Definition,  498. 

Etiology,  498. 

Pathology,  499. 

Symptoms,  500. 

Treatment,  502. 
GANGRENOUS  STOMATITIS 

Synonyms,  353. 

Definition,  353. 

Etiology,  353. 

Symptoms,  354. 

Treatment,  354. 
GANGRENOUS  PHARYNGITIS — 

GARROTILLO 

GASTRALGIA 

Synonym,  409. 

Definition,  409. 

Etiology,  409. 

Pathology,  409. 

Symptoms,  409. 

Diagnosis,  410. 

Prognosis,  410. 

Treatment,  410. 

GASTRECTASIS 

GASTRIC  CATARRH,  ACUTE 

GASTRIC  CATARRH,  CHRONIC.. 
GASTRITIS,  ACUTE 

"         CHRONIC 

"          PARASITIC 

GASTRITIS,  PHLEGMONOUS 

Synonym,  378. 

Definition,  378. 

Etiology,  378. 

Pathology,  378. 

Symptoms,  378. 

Diagnosis,  379. 

Prognosis,  379. 


.498 


.353 


.360 
.167 
409 


.390 
.378 

.379 
.376 
.379 
.379 
.378 


INDEX. 


625 


GASTRITIS,  PHLEGMONOUS,  CON.  .378 

Treatment,  379. 

GASTRODYNIA 409 

GASTRORRHAG  IA 404 

GENERAL,   REMARKS   ON   FEVER 

AND  INFLAMMATION l 

GEOGRAPHICAL  TONGUE 352 

GERMAN  MEASLE& 150 

GIN- DRINKER'S  LIVER 480 

GLANDS,  INFLAMMATION  OF  SALI- 
VARY  358 

GLANDERS 289 

Synonym,  289. 

Definition,  289. 

Etiology,  289. 

Pathology,  289. 

Symptoms,  290. 

Diagnosis,  290. 

Prognosis,  291. 

Treatment,  291. 

GLISSONIAN  CIRRHOSIS 482 

GLUCOSURIA 326 

GLYCOSURIA 326 

GONORRHCEAL  RHEUMATISM 315 

Definition,  315. 

Etiology,  315. 

Pathology,  315. 

Symptoms,  315. 

Diagnosis,  316. 

Prognosis,  316. 

Treatment,  316. 
GOUT 316 

Synonym,  316. 

Definition,  316. 

Etiology,  316. 

Pathology,  317. 

Symptoms,  318. 

Diagnosis,  320. 

Prognosis,  321. 

Treatment,  321. 

GRANULATED  TISSUE 26 

GROWTHS  OF  PERITONAEUM 515 

"         "              "            CAN- 
CEROUS  515 

GROWTHS  OF  PERITONAEUM,  NOD- 
ULAR. .,  ..515 


H^EMATEMESIS 

Synonym,  404. 
Etiology,  404. 
Pathology,  404. 
Symptoms,  405. 


.404 


H^EMATEMESIS,    CONT'D 404 

Diagnosis,  405. 
Prognosis,  405. 
Treatment,  405. 

HAEMOPHILIA 346 

Definition,  346. 

Etiology,  346. 

Pathology,  346. 

Symptoms,  346. 

Diagnosis,  347. 

Prognosis,  347. 

Treatment,  347. 

HEMORRHAGE,  INTESTINAL 441 

"             FROM  THE  PAN- 
CREAS  503 

Etiology,  503. 

Pathology,  503. 

Symptoms,  503. 

Treatment,  504. 

HEMORRHAGIC,  CHRONIC  PERITO- 
NITIS  514 

HEMORRHOIDS 451 

Synonym,  451. 

Definition,  451. 

Etiology,  452. 

Pathology,  452. 

Symptoms,  453. 

Diagnosis,  454. 

Prognosis,  454. 

Treatment,  454. 

HEPATITIS,  INTERSTITIAL 480 

HERPES   LABIALIS 348 

HOB-NAILED  LIVER 480 

HYDROPERITON^UM 516 

HYDROPHOBIA 260 

Synonyms,  260. 

Definition,  260. 

Etiology,  260. 

Pathology,  261. 

Symptoms,  261. 

Diagnosis,  262. 

Treatment,  263. 

HUNGERPEST 97 

HYPER^EMIA  OF  LIVER,  ACTIVE.. 478 
HYPERSECRETION  AND  HYPERACID- 
ITY OF  GASTRIC  JUICE 408 

Symptoms,  408. 

Diagnosis,  408. 

Treatment,  408. 

HYPERSECRETION  OF  THE  SALI- 
VARY GLANDS 356 

Synonym,  356. 


526 


INDEX. 


HYPERSECRETION  OF  THE  SALT- 
VARY  GLANDS,  CONTINUED.  ...356 
Etiology,  356. 
Symptoms,  357. 
Treatment,  357. 

HYPERTROPHY 36 

HYPERTROPHY  OF  THE  TONSILS..368 
HYPODERMIC  INJECTION  OF  QUIN- 
INE IN  MALARIAL  FEVER 241 

ICTERUS 474 

ICTERUS  GRAVIS 476 

ICTERUS  NEONATORUM 474 

INFANTS,  PERITONITIS  IN 512 

INFANTILE  ESTIVAL  ENTERITIS... 464 

INFANTILE  JAUNDICE 474 

INFLAMMATION 17 

Synonyms,  17. 

Definition,  17. 

Etiology,  17. 

Pathology,  18. 

Histological  Elements  Involved,  18 

Bloodvessels,  18. 

Blood  Corpuscles,  18. 

Fixed  Tissue  Cells,  20. 

Exudation,  21. 

Exudation  of  Serous  Mem- 
brane, 21. 

Exudation  of  Mucous  Mem- 
brane, 21. 

Histological  Changes,  23. 

Terminations,  26. 

Symptoms,  27. 

Treatment,  30. 

Dieting,  35. 

INFLAMMATION  OF  THE  CAECUM.. .443 
INFLAMMATION  OF  THE  SALIVARY 

GLANDS ." 358 

INFLAMMATORY  RHEUMATISM 302 

INFLUENZA,  EPIDEMIC 161 

INTERMITTENT  FEVER. 222 

Synonym,  222. 

Definition,  222. 

Etiology,  222. 

Symptoms,  223. 

Diagnosis,  224. 

Treatment,  225. 

INTERMITTENT  FEVER,  MASKED.. 228 
INTESTINAL  COLIC 461 

Definition,  461. 

Etiology,  461. 

Pathology,  461. 


INTESTINAL  COLIC,  CONT'D 461 

Symptoms,  462. 

Diagnosis,  463. 

Prognosis,  463. 

Treatment,  463. 
INTESTINAL  HEMORRHAGE 441 

Synonym,  441. 

Etiology,  441. 

Pathology,  441. 

Symptoms,  441. 

Diagnosis,  442. 

Treatment,  442. 
INTESTINAL  OBSTRUCTION 437 

Definition,  437. 

Etiology  and  Pathology,  437. 

Symptoms,  438. 

Diagnosis,  439. 

Prognosis,  440. 

Treatment,  440. 
INTERSTITIAL  HEPATITIS 4£ 

Synonyms,  480. 

Definition,  480. 

Etiology,  480. 

Pathology,  481. 

Symptoms,  484. 

Diagnosis,  485. 

Prognosis,  485. 

Treatment,  485. 


JAIL  FEVER 

JAUNDICE 

Synonym,  471. 

Definition,  471. 

Etiology,  471. 

Pathology,  472. 

Symptoms,  473. 
JAUNDICE,  INFANTILE.. 

Synonym,  474. 

Etiology,  474. 

Symptoms,  475. 

Treatment,  476. 
JAUNDICE,  MALIGNANT. 

Synonyms,  476. 

Etiology,  476. 

Pathology,  476. 

Symptoms,  477. 

Diagnosis,  477. 

Prognosis,  477. 

Treatment,  477. 
JUNGLE  FEVER.. 


.  90 
.471 


.474 


,/.476 


KARYOKINESIS 


.229 
36 


INDEX. 


627 


LA  GRIPPE 161 

LEPRA 286 

LEPROSY 286 

Synonyms,  286. 

Definition,  286. 

Etiology,  286. 

Pathology,  287. 

Symptoms,  288. 

Diagnosis,  288. 

Prognosis,  288. 

Treatment,  289. 
LIVER,  ABSCESS  OF 486 

Synonym,  486. 

Etiology,  486. 

Pathology,  487. 

Symptoms,  488. 

Diagnosis,  489. 

Treatment,  489. 
LIVER,  ACTIVE  HYPER^EMIA  OF.. 478 

"       ADENOMATA  OF 492 

"       ANGIOMATA  OF 492 

"       CANCER  OF 490 

"       CIRRHOSIS  OF  THE 480 

"       CONGESTION  OF 478 

"       CYSTS  OF... 493 

"       FATTY 493 

"       GIN-DRINKER'S 480 

"       HOB-NAILED 480 

"       TUBERCULOUS 496 

LlTH^MIA 323 

Definition,  323. 

Etiology,  323. 

Pathology,  324. 

Symptoms,  324. 

Diagnosis,  325. 

Prognosis,  325. 

Treatment,  325. 
LOCAL  ADHESIVE  PERITONITIS..  .  .514 

LOCALIZED  PERITONITIS 512 

LOCKJAW 264 

LUES  VENEREA 273 

LUMPY  JAW 291 

LYSSA 260 

MALARIAL  CACHEXIA 251 

MALARIAL  FEVER 216 

Synonyms,  216. 

Definition,  216. 

Etiology,  216. 

Conditions  Which  Oppose.  219.' 

Conditions  Which  Predis- 
pose, 219. 


MALARIAL  FEVER,  CON 297 

General  Pathology,  220. 
MALARIAL  FEVER,  CHRONIC 251 

Synonym,  251. 

Etiology,  251. 

Pathology,  251. 

Symptoms,  251. 

Diagnosis,  252. 

Prognosis,  252. 

Treatment,  253. 

MALARIAL  FEVER,  CONTINUED..  .243 
"  "       PERNICIOUS...  235 

Synonyms,  235. 

Definition,  235. 

Etiology,  235. 

Pathology,  235. 

Symptoms,  235. 

Diagnosis,  239. 

Treatment,  235. 

MALARIAL  FEVER,  REMITTENT  . .  .229 
MALIGNANT  CHOLERA 200 

"  CEDEMA 258 

MALIGNANT  JAUNDICE 476 

Synonyms,  476. 

Etiology,  476. 

Pathology,  476. 

Symptoms,  477. 

Diagnosis,  477. 

Prognosis,  477. 

Treatment,  477. 
MALIGNANT  PURPURIC  FEVER — 344 

"  PUSTULE 258 

MALTA  FEVER 298 

Synonyms,  298. 

Definition,  298. 

Etiology,  298. 

Pathology,  299. 

Symptoms,  299. 

Treatment,  299. 

MAP  TONGUE -352 

MARSH  FEVER 216 

MASKED  INTERMITTENT  FEVER.. 228 
MEASLES « 141 

Synonyms,  141. 

Definition,  141. 

Etiology,  141. 

Pathology,  141. 

Symptoms,  142. 

Atypical  Course,  144. 

Complications  and  Sequelae,  144. 

Diagnosis.  M">. 

Prognosis,  146. 


528 


INDEX. 


MEASLES,  CONTINUED 141 

Treatment,  146. 

MEASLES,  GERMAN 150 

MEDITERRANEAN  FEVER 298 

MELLITURIA 328 

MEMBRANOUS  ENTERITIS 418 

MERCURIAL  STOMATITIS 351 

Definition,  351. 

Etiology,  351. 

Symptoms,  351. 

Treatment,  351. 
MESENTERY,  DISEASES  OF  THE... 470 

MILIARY  FEVER 299 

MILK  SICKNESS 297 

Definition,  297. 

Etiology,  297. 

Pathology,  298. 

Symptoms,  298. 

Diagnosis,  298. 

Prognosis,  298. 

Treatment,  298. 

MORBILLI 141 

MORNING  DIARRHCEA 411 

MOUNTAIN  FEVER 300 

MUCOID  DEGENERATION.  .„ 44 

Mucous  COLIC 419 

Mucous  COLITIS 419 

Synonyms,  419. 

Definition,  419. 

Etiology,  419. 

Pathology,  419. 

Symptoms,  420. 

Diagnosis,  420. 

Treatment,  420. 

MUGUET 352 

MUMPS ... .153 

Synonyms,  153. 

Definition,  153. 

Etiology,  153. 

Pathology,  153. 

Symptoms,  154. 

Treatment,  155. 
MUSCULAR  RHEUMATISM 809 

Synonym,  309. 

Definition,  309. 

Etiology,  309. 

Pathology,  309. 

Symptoms,  309. 

Diagnosis,  310. 

Prognosis,  310. 

Treatment,  310. 
MYALGIA..  ....309 


MYCOSIS  INTESTINALIS 259 

NEAPOLITAN  FEVER 298 

NECROSIS 48 

NERVOUS  DYSPEPSIA 406 

NEW  GROWTHS  IN  THE  LIVER 490 

NEW  GROWTHS  IN  PERITONAEUM.. 515 
NODULAR  GROWTHS  IN  THE  PERI- 
TONAEUM  515 

NOMA 353 

NON-MALIGNANT  TUMORS  OF  THE 
STOMACH 453 

OBSTRUCTION  OF  BILIARY  DUCT.  .503 

OBSTRUCTION  OF  THE  BOWEL 437 

(ESOPHAGUS,  INFLAMMATION  OF.. 371 

"  OBSTRUCTION  OF.  .  .373 

Etiology,  373. 

Pathology,  373. 

Symptoms,  373. 

Treatment,  374. 

(ESOPHAGUS,  FUNCTIONAL  DIS- 
EASE OF 374 

CESOPHAGITIS 371 

Synonym,  371. 

Definition,  371. 

Etiology,  371. 

Pathology,  371. 

Symptoms,  372. 

Diagnosis,  372. 

Prognosis,  372. 

Treatment,  372. 

PALUDAL  FEVER 216 

PANCREAS,  ACUTE  lNFLAMMAT'N..504 

"          CALCULI 507 

"          CANCER  OF 507 

"          CHRONIC  INFLAMMA- 
TION OF 505 

PANCREAS,  CYSTS 507 

"  DISEASES  OF 503 

(i  FATTY  DEGENERATI'N.506 
"  HEMORRHAGE  FROM... 503 
"  WAXY  DEGENERATI'N.508 

PARASITIC  GASTRITIS 379 

"  STOMATITIS 352 

Synonyms,  352. 
Definition,  352. 
Etiology,  352. 
Pathology,  352. 
Symptoms,  353. 
Treatment,  353. 


529 


PAKENCHYMATOUS  DEGENERA- 
TION*   4~2 

PATHOGENIC  BACILLI 67 

"  Cocci 66 

"  SPIRILLI 67 

PEPTIC  ULCER 392 

Synonyms,  392. 

Definition,  392. 

Etiology,  392. 

Pathology,  393. 

Symptoms,  394. 

Diagnosis,  395. 

Prognosis,  395. 

Treatment,  3%. 
PERIPROCTITIS 450 

Definition,  450. 

Etiology,  450. 

Pathology,  451. 

Symptoms,  451. 

Treatment,  451. 

PERISTALTIC  UNREST 411 

PERITONAEUM,  ACUTE  INFLAMMA- 
TION OF 508 

PERITONAEUM,  INFLAMMATION  OF.508 
PERITONAEUM,  NEW  GROWTHS  IN. 515 
PERITONAEUM,  NODULAR  GROWTHS 

IN  THE 514 

PERITONAEUM,  TUBERCULOSIS  OF..515 
PERITONITIS,  LOCAL  ADHESIVE.  .  .514 

"  APPENDICULAR — 513 

"  CHRONIC 513 

"  CHRONIC   HEMOR- 

RHAGIC 514 

PERITONITIS,  DIFFUSE 514 

"  IN  INFANTS 512 

"  LOCALIZED 512 

PELVIC 512 

"  PROLIFERATIVE 514 

"  SUBPHRENIC 513 

PERNICIOUS  FEVER 235 

PERNICIOUS  MALARIAL  FEVER.... 23"> 

Synonyms,  235. 

Definition,  2.S.". 

Etiology,  235. 

Pathology,  235. 

Symptoms,  235. 

Diagnosis,  23S). 

Treatment,  235. 

PERTUSSIS 156 

PETECHI AL  FEVER 1  < '  l 

PHARYNGEAL  CATARRH 360 

Synonym,  360. 

34 


PHARYNGEAL  CATARRH,  cox :wo 

Etiology,  360. 
Pathology,  361. 
Symptoms,  361. 
Treatment,  361. 

PHARYNGITIS,  PHLEGMONOUS 360 

"  SICCA 

PHARYNX,  ABSCESS  OF ::r.n 

"          ACUTE  INFLAMMATION.:;:.^ 
"  CHRONIC INFLAMMAT'N  :n;o 

"          GANGRENE  OF 360 

"  ULCERATION   OF 362 

PHLEGMCNOUS  ENTERITIS 418 

"  GASTRITIS 378 

Synonym,  378. 
Definition,  378. 
Etiology,  378. 
Pathology,  378. 
Symptoms,  378. 
Diagnosis,  379. 
Prognosis,  379. 
Treatment,  379. 
POCKEN 108 

PODAGRA 316 

PORTAL  VEIN,  DISEASES  OF 479 

Pox 273 

PROCTITIS 449 

Synonyms,  449. 

Definition,  449. 

Etiology,  449. 

Pathology,  449. 

Symptoms,  449. 

Diagnosis,  449. 

Prognosis,  450. 

Treatment,  450. 

PROLIFERATIVE  PERITONITIS..  ..514 
PSEUDO-MEMBRANOUS  ENT  ERiTis.418 

Synonyms,  418. 

Definition,  418. 

Etiology,  418. 

Pathology,  419. 

Symptoms,  419. 

Treatment,  419. 

PTYALISM 

PURPURA 

"         HEMORRHAGICA.  . .  -'M-'5 

Symptoms,  344. 

Treatment,  344. 
PURPURIC  FEYKK.  MALIGNANT  .  :!44 

PUSTULE,  MALIGNAXT 

Pus 

PUTRID  SORE  MOUTH :'*">o 


530 


INDEX. 


PYAEMIA 

Synonym,  196. 

Definition,  196. 

Etiology,  196. 

Pathology,  197. 

Symptoms,  198. 

Diagnosis,  199. 

Prognosis,  199. 

Treatment,  199. 
PYORRHCEA  ALVEOLARIS. 

Definition,  354. 

Etiology,  355. 

Pathology,  355. 

Symptoms,  355. 

Treatment,  355. 

QUINSY 

Synonyms,  36. 
Definition,  366. 
Etiology,  366. 
Pathology,  366. 
Symptoms,  367. 
Diagnosis,  367. 
Prognosis,  367. 
Treatment,  367. 


196 


.354 


.366 


RABIES 

RACHITIS 

RECTITIS 

RECTO-COLITIS 

RECTUM,  INFLAMMATION  OP 

RELAPSING  FEVER 

Synonyms,  97. 

Definition,  97. 

Etiology,  97. 

Pathology,  97. 

Symptoms,  98. 

Diagnosis,  99. 

Prognosis,  100. 

Treatment,  100. 
REMITTENT  FEVER 

Synonyms,  229. 

Definition,  229. 

Etiology,  229. 

Pathology,  229. 

Symptoms,  230. 

Diagnosis,  231. 

Prognosis,  232. 

Treatment,  232. 
REMITTENT  MALARIAL  FEVER. 

REMITTO-TYPHUS  FEVER 

RETROPHARYNOEAL  ABSCESS.  . 


.260 
.333 
.449 
.425 
.449 
.  97 


.229 


.229 
.343 
.360 


RHACHITIS 333 

RHEUMATISM :;ui 

Definition,  301. 

Etiology,  301. 

RHEUMATISM.,   ACUTE    ARTICU- 
LAR  :jo^ 

RHEUMATISM,  CHRONIC  ARTICU- 
LAR  307 

RHEUMATISM,  INFLAMMATORY 302 

"          GONORRHCEAL 315 

"  MUSCULAR 309 

"          SUBACUTE  ARTIC- 
ULAR  306 

RHEUMATIC  FEVER 302 

"  GOUT 316 

RHEUMATOID  ARTHRITIS 311 

RICKETS 333 

Synonym,  333. 

Definition,  333. 

Historical  Note,  333. 

Etiology,  334. 

Pathology,  335. 

Symptoms,  335. 

Diagnosis,  337. 

Prognosis,  337. 

Treatment,  337. 

ROCK  FEVER _!'* 

ROSE -187 

ROTHELN 150 

ROUND  ULCER 392 

RUBELLA 150 

RUBEOLA 141 

Synonym,  141. 

Definition,  141. 

Etiology,  141. 

Pathology,  141. 

Symptoms,  142. 

Diagnosis,  145. 

Prognosis,  146. 

Treatment,  146. 
RUMINATION 411 

SALIVA,  ARREST  OF 357 

"  HYPERSECRETION  OF 356 

SALIVARY  GLANDS,  INFLAMMATI'NSSS 

SARCOMA  OF  THE  LIVER 492 

SCARLATINA 128 

SCARLET  FEVER 128 

Synonyms,  128. 

Definition,  128. 

Etiology,  128. 

Pathology,  129. 


INDEX. 


531 


SCARLET  FEVER,  CONTINUED. 

Symptoms,  130. 

Complications  and  Sequelae, 

Diagnosis,  136. 

Prognosis,  137. 

Treatment,  137. 

SCARLET  BASH 

SCLEROSIS  OF  THE  LIVER 

SCORBUTUS  

SCROFULA 

Definition,  344. 

Etiology,  344. 

Symptoms,  345. 

Diagnosis,  345. 

Prognosis,  345. 

Treatment,  345. 
SCURVY 

Synonym,  338. 

Definition,  338. 

Etiology,  338. 

Pathology,  339. 

Symptoms,  339. 

Diagnosis,  340. 

Prognosis,  340. 

Treatment,  340. 
SCURVY,  INFANTILE 

Treatment,  342. 
SEPTICAEMIA 

Definition,  193. 

Etiology,  194. 

Symptoms,  194. 

Diagnosis,  195. 

Prognosis,  195. 

Treatment,  196. 

SHIP  FEVER 

SIMPLE  CONTINUED  FEVER 

Synonyms,  293. 

Definition,  293. 

Etiology,  293. 

Symptoms,  294. 

Diagnosis,  295. 

Prognosis,  295. 

Treatment,  295 

SIMPLE  STOMATITIS 

SLOUGH 

SMALL-POX , 

Synonyms,  108. 

Definition,  108. 

Etiology,  108. 

Pathology,  109. 

Symptoms,  111. 

Diagnosis,  116. 


..128 
135. 


.128 
.480 
.338 
.344 


.341 
.  193 


.  90 
.293 


.348 
.  26 
.108 


SMALL-POX,  CONTINUED 108 

Prognosis,  116. 
Treatment,  117. 

SOOR 352 

SPASMODIC  CHOLERA 200 

SPIRILLI,  PATHOGENIC 117 

SPIRILLUM  FEVER 97 

SPLENIC  FEVER i">8 

SPORADIC  CHOLERA 4:11 

SPOTTED  FEVER 101 

ST.  ANTHONY'S  FIRE 187 

STENOSIS  OF  THE  BILIAKY  1  >r<  -rs  ..:><>.•{ 
STOMACH,  ACUTE  INFLAMMATI'N..:^*; 

AMYLOID .4:11 

"  CANCKR  OF 

"  CHRONIC  INFLAMMAT'N  :!7'.i 

"          DILATATION  OF 3!H) 

FUNCTIONAL  DiSEASEs.406 
HEMORRHAGE  FROM . .  4<>4 
NON-MALIGN'T  TUMORS  40:: 
PARASITIC  INFLAMMA- 
TION OF :<7<i 

STOMACH,  PHLKCMOXOVS  INFLAM- 
MATION OF :!7s 

STOMACH,  TUMORS  OF 403 

STOMATITIS 348 

"         APHTHOUS 349 

'•         FOETID :•::.<> 

GANGRENOUS 353 

"         MERCURIAL 351 

"         PARASITIC -'t.~>2 

"         SIMPLE 

STRUMA 344 

SUBACUTE  ARTICULAR  KHKIMA- 

TISM 306 

SUBPHRENIC  PERITONITIS 

SUMMER  COMPLAINT  OF  CHILDR'X  4r>4 

SUPPURATIVE  HEPATITIS 486 

"  LENITIS 378 

SWAMP  FEVER 

SYPHILIS 273 

Synonyms;  27.'.. 

Definition,  273. 

Histori  -al  Note,  273. 

Etiology,  274. 

General  Pathology.  -2~'>. 

Acquired  Pathology  and  Symp- 
toms, 276. 

Congenital  Pathology  and 
Symptoms,  27t>. 

(Jrnrnil  Diagnosis,  283. 

Prognosis,  284. 


532 


INDEX. 


SYPHILIS,  CONTINUED 27:j 

Treatment,  284. 
SYPHILITIC  CIRRHOSIS 482 

TETANUS 264 

Synonyms,  264. 

Definition,  264. 

Etiology,  264. 

Pathology,  264. 

Symptoms,  266. 

Diagnosis,  266. 

Prognosis,  266. 

Treatment,  266. 

THRUSH 352 

TONSILS,  ABSCESS  OF 366 

"         CHRONIC  INFLAMMAT'N.  366 
"         FOLLICULAR  INFLAMMA- 
TION OF 364 

TRISMUS 264 

TROPICAL  TYPHOID  FEVER 235 

TUBERCULOSIS 50 

"  OF  THE  LIVER 496 

TUBERCULAR  PERITONITIS 515 

TUBULAR  DIARHHCEA 419 

Tussis  CONVULSIVA 156 

TYPHLITIS 443 

Definition,  443. 

Etiology,  443. 

Pathology,  444. 

Symptoms,  444. 

Diagnosis,  444. 

Treatment,  444. 
TYPOHID  FEVER t>9 

Synonyms,  69. 

Definition,  69. 

Historical  Note,  69. 

Etiology,  69. 

Pathology,  71. 

Symptoms,  74. 

Temperature,  77. 

Relapses,  80. 

Diagnosis,  80. 

Prognosis,  81. 

Treatment,  81. 

Hyperpyrexia,  84. 

Delirium,  86. 

Gastric  Complications,  87. 

Special  Septic  Conditions,  87. 

Diarrhoea,  88. 

Tympanites,  88. 

Intestinal  Hemorrhage,  83. 

Constipation,  89. 


TYPHOID  FEVER,  CON.  69 

Convalesence,  89. 
TYPHO-MALARIAL  FEVER "...  .243 

Synonyms,  243. 

Definition,  24.'5. 

Nature  Of,  211. 

Etiology,  245. 

Symptoms,  246. 

Diagnosis,  248. 

Prognosis,  249. 

Treatment,  24! ». 

TYPHOID  TUBERCULOSIS 2<>s 

TYPHUS  FEVER 90 

Synonyms,  90. 

Definition,  90. 

Etiology,  90. 

Pathology,  91. 

Symptoms,  92. 

Temperature,  93. 

Diagnosis,  95. 

Prognosis,  95. 

Treatment,  96. 
TYPHUS  ICTERODES.  ...208 


ULCER,    AMYLOID 421 

"         CANCEROUS 422 

"         CATARRHAL  AND  FOLLIC- 
ULAR  421 

ULCER,   DUODENAL -121 

"         EMBOLIC .421 

"        MERCURIAL..  421 

PEPTIC 420 

PERITONEAL 422 

•  "    ROUND,  OF  STOMACH :t!t2 

"    STERCORAL 42! 

"         SYPHILITIC 422 

TUBERCULAR 422 

"        UR^EMIC 422 

ULCERATION 2r> 

OF  INTESTINES 42<» 

OF  PHARYNX :t<>2 

Etiology,  362. 
Symptoms,  363. 
ULCERATIVE  STOMATITIS -T)0 

VACCINATION 120 

History,  120. 

Definition,  120. 

Development  of  Vesicle,  122. 

Method,  122. 

VOMITO  NEGRO -"' 

VARICELLA 123 

i 


INDEX. 


VARIOLA. 


108 


WAXY"  DEGENERATION  OF  THE 

PANCREAS 506 

WEIL'S  DISEASE 295 

Synonyms,  295. 

Definition,  295. 

Etiology,  296. 

Pathology.  296. 

Symptoms,  296. 

Diagnosis,  296. 

Prognosis,  296. 

Treatment,  297. 
WHOOPING  COUGH 156 

Synonyms,  156. 

Definition,  156. 

Historical  Note,  156. 

Etiology,  156. 

Pathology,  157. 


\VHOOPING  COUGH,  CONTINUED    i.,>. 

Symptoms,  157. 

Complications  and  Sequel :i>.  l.V.i. 

Treatment,  159. 
WOOL-SORTER'S  DISEASE..          .  iMo 


XEROSTOMA.. 


YELLOW  FEVER 

Synonyms,  208. 

Definition,  208. 

Etiology,  208. 

Pathology.  2»>!». 

Symptoms.  21 1. 

Diagnosis,  213. 

Prognosis,  213. 

Treatment,  214. 
YELLOW  JACK.. 


.381 

.208 


A    Book   Every   Stndent    and    Practitioner    of    Medicine 

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